The symbolic consumption of cosmetic surgery: exploring the sociocultural context and the dynamics of self-concept

ii ii DIREITOS DE AUTOR E CONDIÇÕES DE UTILIZAÇÃO DO TRABALHO POR TERCEIROS Este é um trabalho académico que pode ser utilizado por terceiros desde que respeitadas as regras e boas práticas internacionalmente aceites, no que concerne aos direitos de autor e direitos conexos. Assim, o presente trabalho pode ser utilizado nos termos previstos na licença abaixo indicada. Caso o utilizador necessite de permissão para poder fazer um uso do trabalho em condições não previstas no licenciamento indicado, deverá contactar o autor, através do RepositóriUM da Universidade do Minho. Licença concedida aos utilizadores deste trabalho Atribuição CC BY https://creativecommons.org/licenses/by/4.0/ iii ACKNOWLEDGMENT This PhD journey has truly been a life-changing experience, and I would have never been able to complete this journey without the love, support, and guidance that I have received from my supervisor, family, and friends. I would like to express my deepest gratitude to my supervisor Professor Cláudia Simões who was there all along, believing in me, and always making time, even in her busiest times. Thank you for your continuous support and guidance throughout this journey. I am forever grateful for your help in making every step of this PhD simpler. I cannot express my gratitude to my family for their continuous support and love. First and foremost, my husband who has been my most enthusiastic cheerleader, an amazing partner, and a best friend. Thank you for being there every step of the way, working late nights and long hours supporting me. Without your help, this PhD journey could not have been completed. My mother, for her unconditional love, care, and encouragement. My friends and colleagues who supported me throughout this journey. Lastly, I would like to dedicate this thesis to the memory of my beloved father, I hope I made you proud. iv STATEMENT OF INTEGRITY I hereby declare having conducted this academic work with integrity. I confirm that I have not used plagiarism or any form of undue use of information or falsification of results along the process leading to its elaboration. I further declare that I have fully acknowledged the Code of Ethical Conduct of the University of Minho. v O Consumo Simbólico da Cirurgia Plástica: Explorando o Contexto Sociocultural e a Dinâmica do Autoconceito RESUMO Ao longo da última década tem havido um crescente interesse académico no estudo da imagem corporal e dos comportamentos ligados à mudança corporal. A investigação tem conceptualizado a cirurgia estética como parte de um espectro de comportamentos de mudança corporal que tem sido normalizado nos últimos anos. A investigação dentro destes temas reconhece que a maioria dos estudos são realizados no Ocidente e que diferentes contextos culturais justificam investigação. Assim, este estudo investiga o contexto egípcio, contribuindo para uma explicação contextualizada da imagem corporal e dos comportamentos de mudança corporal. Esta tese oferece um quadro psicológico-social para a compreensão dos múltiplos caminhos através dos quais a imagem corporal da mulher, e as atitudes e comportamentos relativamente à cirurgia estética são moldados pela sociedade contemporânea. Este estudo apresenta dois objectivos fundamentais. Em primeiro lugar, examina o impacto do contexto sociocultural, influências psicológicas, materialismo a nível individual e religiosidade nas atitudes em relação à cirurgia estética; e o impacto das preocupações de aparência facial na relação entre atitudes e intenções de submeter-se à cirurgia estética. Em segundo lugar, apresenta evidência empírica quantitativa, testando o modelo conceptual. Os resultados do estudo revelam o papel significativo do contexto sociocultural, sugerindo os meios de comunicação social (Instagram) como uma importante fonte de pressões sobre a aparência. O Instagram contribui para a interiorização dos ideais de beleza e impulsiona comparações centradas na aparência. O estudo destaca a interacção entre as construções socioculturais e psicológicas ao afectar as atitudes das mulheres em relação à cirurgia estética. Os resultados corroboram os princípios da teoria da objectificação e do modelo de impacto da cultura do consumidor na vontade das mulheres em considerar a cirurgia estética. Os resultados do estudo também oferecem novos conhecimentos sobre a investigação da imagem corporal, examinando as preocupações com a aparência facial como um aspecto da imagem corporal derivada da especificidade cultural e destacando o papel protector que a religião desempenha nas atitudes da cirurgia estética na cultura egípcia. Palavras-chave: Cirurgia Estética, Consumo Simbólico, Imagem Corporal, Ideais de Beleza, Contexto Sociocultural. vi The Symbolic Consumption of Cosmetic Surgery: Exploring the Sociocultural Context and the Dynamics of Self-concept ABSTRACT There has been an increasing scholarly interest in the study of body image and body change behaviours in the last decade. Contemporary research has conceptualized cosmetic surgery as part of a spectrum of body change behaviours that has been normalized in recent years. Research within these themes has acknowledged that most studies are carried in the West and that different cultural contexts warrants investigation. Hence, this study investigates the Egyptian context contributing to a more nuanced and contextualized explanation of body image and body change behaviours. This thesis provides a social psychological framework for understanding the multiple pathways by which women’s body image, and cosmetic surgery attitudes and behaviours are shaped in contemporary society. The objective of this thesis is twofold. First, it examines the impact of the sociocultural context, psychological influences, individual level materialism and religiosity on attitudes towards cosmetic surgery; and the impact of facial appearance concerns on the relationship between attitudes and intentions to undergo cosmetic surgery. Second, it presents empirical quantitative evidence by testing the conceptual model. The findings of the study reveal the significant role of the sociocultural context, suggesting social media (Instagram) as a major source of appearance pressures. Instagram contributes to the internalization of beauty ideals and drives appearance-focused comparisons. The study highlights the interplay between sociocultural and psychological constructs in affecting women’s attitudes towards cosmetic surgery. Results provided empirical evidence to the basic tenets of objectification theory and consumer culture impact model in women’s willingness to consider cosmetic surgery. Findings of the study also provide new insights into body image research by examining facial appearance concerns as an aspect of body image which allowed for cultural specificity and highlighting the protective role that religion plays within cosmetic surgery attitudes in the Egyptian culture. Keywords: Cosmetic Surgery, Symbolic Consumption, Body Image, Beauty Ideals, Sociocultural Context. vii INDEX ACKNOWLEDGMENT ....................................................................................................... iii RESUMO .......................................................................................................................... v ABSTRACT ...................................................................................................................... vi LIST OF FIGURES ............................................................................................................ xi LIST OF TABLES .............................................................................................................. xi CHAPTER 1 - INTRODUCTION AND BACKGROUND ........................................................... 1 1.1. Introduction ............................................................................................................................ 1 1.2. Research Background ............................................................................................................. 1 1.3. Rationale for the Study ............................................................................................................ 3 1.4. Research Questions and Objectives ......................................................................................... 6 1.5. Expected Contribution ............................................................................................................. 7 1.6. Research Methodology ............................................................................................................ 8 1.7. Thesis Structure ...................................................................................................................... 9 CHAPTER 2 - BEAUTY AND COSMETIC SURGERY ........................................................... 11 2.1. Overview ............................................................................................................................... 11 2.2. Beauty and Society ............................................................................................................... 11 2.2.1. Feminine Beauty Standards ........................................................................................... 14 2.2.2. A Sociocultural Perspective of Beauty ............................................................................. 17 2.2.3. The Westernization and Universality of Beauty ................................................................ 18 2.3. Cosmetic Surgery.................................................................................................................. 22 2.3.1. Types of Cosmetic Surgery ............................................................................................. 23 2.3.2. Cosmetic Surgery as a Feminine Practice ....................................................................... 26 2.3.3. Normalization of Cosmetic Surgery................................................................................. 28 2.3.3.1. Capitalism and Consumer Culture .......................................................................... 29 2.3.3.2. Technology and Media ............................................................................................ 30 2.3.3.3. Feminism and Objectification .................................................................................. 30 2.4. Cosmetic Surgery in Egypt .................................................................................................... 32 2.4.1. Collectivistic Culture ...................................................................................................... 33 2 presence of some degree of body discontent is prevalent in women of all ages and races, that it is considered to be normative (Karazsia, Murnen & Tylka, 2017; Keski-Rahkonen & Mustelin, 2016; Runfola et al., 2013). In fact, beauty practices and body change behaviours have been mainly pursued by women (Lee, Choi & Johnson, 2022). The pursuit of beauty culminates in risky appearance management behaviours (e.g., extreme body makeovers, cosmetic procedures) for many women. For that reason, body image research has become more prominent in the past decade. It has become a theme of discussion in psychology, sociology, and media studies due to its significant influence on the mental and physical health, and social functioning of women. The pursuit of beauty through alteration of physical appearance is a growing trend. Cosmetic surgery (CS) practice has recently spread rapidly across the globe particularly for women who make up the largest group of cosmetic surgery consumers (Searing & Zeilig, 2017; Gilleard & Higgs, 2013). CS provides a paradigm shift in the perceptions of beauty, whereby beauty is no longer a gift bestowed by God, but rather something that is pursued and earned by women (Dingman, Melilli Otte & Foster, 2012). CS has evolved from a medical procedure to a social phenomenon, it has been normalized and accepted as a form of self-enhancement (Dingman, Melilli Otte & Foster, 2012). Therefore, the efforts of academia to understand CS phenomenon have been increasing over the last decade (Eom, Yu & Han, 2019). However, the literature suggests that body image research and CS studies have been mainly investigated in the western world and primarily among white women (Schaefer et al., 2018). The globalized spread of CS in developing countries has been alluded to but not yet been systematically examined. Recent research supports the need for examining body image and CS behaviours in different cultural contexts (Yoon & Kim, 2020; Stojcic, Dong & Ren, 2020). The demand for CS in the Middle East has been on the rise (Amiri et al., 2021; Al-Saiari & Bakarman, 2015; ISAPS, 2017), which raises many concerns as Middle Eastern societies are different than their western counterparts. Middle Eastern societies are conservative, unlike liberal societies of the west. Religious values (Islamic values) are embedded in the culture and contradicts with CS consumption. Patriarchy permeates society at so many levels. Nonetheless, these factors did not deter the pervasiveness and normalization of CS in the region. Even with economic recessions and financial constraints, CS consumption has not decreased. The emergence of body change behaviours in this region is associated with the process of globalisation and its accompanied sociocultural factors. It is undeniable that globalization and westernization have a great impact on the homogenization of beauty ideals. CS fuels a monoculture because surgery often emulates one particular kind of beauty that is dictated by the West (Coy-Dibley, 2016; Calogero, Boroughs, & Thompson, 2007). Hence, women in different cultures 3 are adhering to western ideals of beauty (Amiri et al., 2021). Considering these concerns, it is essential to broaden the spectrum of body image and CS studies to new contexts and cultures. As such, this thesis will examine CS consumption in the Middle East, particularly Egypt. The topic of CS is complex, understanding the intricacies and the multi-layered reason for its growth encompasses different academic fields. The multidisciplinary nature of the study of body image and CS allows for a multitude of theoretical perspectives such as gender, media, consumer culture, body image, psychology, sociology, ethics among others. In this study, a social psychological framework is adopted, integrating different theoretical perspectives for understanding the multiple pathways by which women’s body image, and cosmetic surgery attitudes and behaviours are shaped in contemporary society. 1.3. Rationale for the Study Beauty is a gender related category, whereby men and women occupy different positions on physical attractiveness. Women are the focus of the beauty culture in contemporary society. Although the topic is not new, it is a matter of discussion in social psychology, evolutionary, and sociocultural theory. Researchers suggest different reasons for attributing beauty to women. Feminist research argues that beauty ideals are considered to have stemmed from patriarchal society that has strict and often unattainable standards of beauty for women, as part of a culture reducing women to objects rather than subjects (Sun, 2018b; Calogero et al., 2014). Society promotes an ideology in which the value of a woman is determined predominately, if not entirely, by her physical appearance. Accordingly, women are socialised to build their self-esteem around their physical appearance. This then leads to some women seeking a physical outlet, like a cosmetic procedure, in order to meet society’s expectations and address their psychological distress (Sun, 2021; Vaughan‐Turnbull & Lewis, 2015). Hence, examining the repercussions of self-objectification and self-surveillance in the Egyptian culture would further contribute to the body of knowledge concerned with body image and body-change behaviours. Research supports that female beauty ideology has often been used in the capitalist system to develop a consumer society for beauty products and services (Marcuse, 2013). This ideology makes women believe in beauty image as something which should be maintained and enhanced. Consumer culture supports the objectification of women in contemporary society to promote the consumption of goods and services that enhance the body beauty. The whole beauty/cosmetic industry is thriving on creating and sustaining the need for women to look beautiful (Greenfield, 2018; Engeln, 2017). Materialism is presumed to be a core characteristic of this consumer culture (Cleveland, Laroche & Papadopoulos, 2016). Recent research supports that objectifying environments and burgeoning consumer societies 4 encourage people to value their physical appearance and normalize the pursuit of beauty through CS (Li & Xiao, 2021; Ching & Xu, 2019). Hence, examining the globalization of consumer culture and its manifestations in less developed countries such as Egypt would provide new directions for this research. For that reason, the present study examines the dynamics of self-surveillance as a result of objectification, and materialism on attitudes towards CS from the dual perspective of objectification theory and consumer culture impact model. Scholars suggest that beauty ideals represent culturally prescribed and endorsed ideals that incorporate various features of the human face and body, and thus defines what constitutes beauty within a culture (Calogero, Boroughs, & Thompson, 2007). Nevertheless, globalization has influenced socio-cultural contexts such as the middle East via increased influx of western ideas through various media, particularly social media. Many cultures are configuring western standards of beauty to be the universal standards of feminine beauty (Chen et al., 2020). As such, CS has been normalized in the Middle East, and Egypt is no exception (Amiri et al., 2021). Sociocultural models of body image were developed with primarily white women in western contexts; however, research indicates that investigating these models outside that particular demographic warrants investigation (Schaefer et al., 2018). The literature suggests a more nuanced, contextualized explanation of body image and CS culture in non-western societies (Leem, 2017). Hence, this research broadens the spectrum and explore perceptions of beauty and CS in a cultural context that is understudied (Amiri et al., 2021). An important factor that influences individuals’ attitudes and behaviours is religion, and hence its association with CS is not surprising (Muslu & Demir, 2020). This is particularly relevant in Middle Eastern cultures whereby religion is immersed in the culture and interpreted as a critique of Western values and beauty ideals. Previous research suggested that religiously conservative individuals have stricter views about sins of vanity and more likely to perceive cosmetic alteration as a direct contravention to their religious beliefs (Furnham & Levitas, 2012). Research exploring religiosity as a possible factor predicting positive attitudes and intentions towards CS is sparse; the association between CS consideration and religiosity remains unclear (Abbas & Karadavut, 2017). Further research could explore whether this effect is found in all religions, because studies have examined religiousness, not a particular religion per se. In Egypt, Islam is the dominant religion that is followed by the majority of the population. Hence, examining the role of religious beliefs and values (Islam) on shaping attitudes towards CS particularly in such context deserves greater research attention. The literature likewise suggests that antecedents to body modification behaviours such as CS have yet to arrive at a concrete conclusion and needs further development (e.g., Tsiotsou & Klaus, 2021; Wright, 5 2017). As yet research in this field shows three main research trends: studies examining the psychosocial characteristics associated with CS consumers (Yoon & Kim, 2020; Milothridis et al., 2016). Studies on factors associated with attitude and intentions for CS such as self-objectification (Calogero, Pina, Park, & Rahemtulla, 2010), materialistic values (Henderson-King & Brooks, 2009). More recently, researchers have started to investigate the influence of social media, celebrity worship, and social media influencers on individuals' attitudes toward CS (Seekis & Barker, 2022; Gupta et al., 2020; Arab et al., 2019). Scholars in the field are demanding more research in understanding the perceptions regarding CS in contemporary society and the factors contributing to its popularity (Amiri et al., 2021; Wright, 2017). Hence, this research provides a social psychological framework that integrates sociocultural and psychological factors to gain a deeper understanding to the multiple pathways by which women’s body image, and cosmetic surgery attitudes and behaviours are shaped in contemporary Egyptian society. Studies have examined how societal ideals of beauty are transmitted via sociocultural channels such as media, peers, and family (Davis & Arnocky, 2020; Lin & Raval, 2020; De Vries et al., 2016). There is substantial literature on mainstream media effects on body image concerns of young women. A recent growing body of research is addressing the effect of social media particularly Instagram on women’s body image (Baker, Ferszt & Breines, 2019; Hendrickse et al., 2017; Cohen, Newton-John & Slater, 2017; Holland &Tiggemann, 2017). Given the heavy online presence of young adults, particularly women, and the distinctive attributes of social media such as the interactive format, strong peer presence and the photo-based content that is shared, it is crucial to investigate how social media affect body image perceptions and psychological wellbeing (Chatzopoulo, Filieri & Dogruyol, 2020; Fardouly, Pinkus & Vartanian, 2017; Williams & Ricciardelli, 2014; Perloff, 2014). Recent research supports the need for examining the dynamics of social media and how it informs many understandings of beauty pressures that exist today (Hogue & Mills, 2019; Baker, Ferszt & Breines, 2019; Elias et al., 2017). It is therefore pertinent to investigate the effect of Instagram, a photo-based social media platform in constructing beauty ideals and influencing young women’s body image. Research regarding sociocultural model of body image has been applied primarily in the realm of body weight and shape, particularly focusing on body dissatisfaction and thin ideals of attractiveness (Tiggemann, 2011). Research supports the need for more expansive conceptualizations and models of body image and embodiment (Williams & Ricciardelli, 2014). Further robust research is needed to clarify the effect of various social media platforms on other aspects of body image such as facial satisfaction (Alkadhimi, 2021). Hence, this study considers broader conceptualizations of body image by focusing on facial appearance, considering that Instagram provides a new reality of filtered beauty and ideal facial 6 images that may reduce satisfaction with facial appearance and desire for CS consideration (Seekis & Barker, 2022; Di Gesto et al., 2022; Sampson et al., 2020; Tiggemann, Anderberg & Brown, 2020). This study integrates prominent theories of body image to develop and test a conceptual model that will help researchers better understand the effects of sociocultural influences, psychological processes, and individual level materialism on CS consumption among Egyptian women. In addition, this study plans to examine the role of religion in shaping individuals’ attitudes towards CS. The research also aims to examine how facial appearance concerns can affect the relationship between attitudes toward CS and intentions to undergo CS. These foundations of investigation shall add to the body of academic literature. 1.4. Research Questions and Objectives To overcome gaps in the literature highlighted previously, this thesis attempts to answer the researchable questions: “what is the impact of sociocultural influences, psychological influences, individual level materialism, and religiosity in the attitudes towards cosmetic surgery? and “what is the impact of facial appearance concerns on the relationship between attitudes and intentions to undergo cosmetic surgery?”. Given these research questions, the objective of this thesis is twofold: First it attempts to provide a deeper understanding of body image and body modification behaviours in a sociocultural context that is yet to be explored. Second, it intends to examine the interplay between the sociocultural influences and the psychological processes that influence CS attitudes and intentions, providing empirical quantitative evidence. The objectives of this research are presented below, next to each objective is the chapter in which it is discussed and addressed. 1. Provide a critical review and identify gaps in the literature related to body image and body change behaviours (CS) (Chapter 2). 2. Integrate theories and individual-level constructs in order to develop a conceptual framework that examines the factors that influence CS attitudes and intentions (Chapter 3). 3. Develop an appropriate research methodology to collect and analyse data to address the research question (Chapter 4). 4. Empirically examine the impact of sociocultural influences, psychological influences, individual level materialism, and religiosity in attitudes towards CS; and the impact of facial appearance concerns on the relationship between attitudes and intentions to undergo cosmetic surgery (Chapter 5). 7 5. Critically discuss findings of current research and compare them to prior findings within the literature (Chapter 6). 6. Highlight the theoretical contributions and practical implications of the study and identify limitations and areas for future research (Chapter 7). For the comprehension of the phenomenon under study, the research background was grounded in the sociocultural model of body image and body change behaviours literature supported by social comparison and objectification theory. Additionally, consumer culture impact model provided theoretical insights to the symbolic consumption of CS. The study encompasses individual consumers of cosmetic surgery, the unit of analysis is the individual Egyptian female consumer. 1.5. Expected Contribution From fulfilling these objectives this research aims to contribute to existing body of knowledge in the following ways: • Providing a deeper understanding of body image and a form of body change behavior (CS) in a new sociocultural context, which, to the best of our knowledge, has not yet been a subject of scientific discussion and empirical examination. • The current study integrates and extends aspects of objectification theory and consumer culture impact model to understand CS consideration in Egyptian women. • Focusing on the interplay between sociocultural and psychological constructs can strongly contribute to the academic body of knowledge and fill research gaps in the literature concerning body image, and body-change behaviors. • The current study contributes to the sociocultural model of body image (tripartite influence model) by focusing on social media as a major source of appearance pressures. Incorporating an individual construct that has been subject to limited research in the CS context (i.e., religiosity). Also, concentrating on a salient cultural concern when attempting to understand body image issues and cosmetic surgery, facial appearance concerns. • The current study includes younger women in its empirical component as well as middle-aged women (18-60 years), as recent studies have indicated a recent decrease in the average age of cosmetic surgery consumers. • The conceptual model proposed by this study further clarifies antecedents to CS attitudes and intentions among women, which will aid social media marketers and health policymakers in the 8 design and execution of social media literacy programs and campaigns that would improve the psychological well-being of women in society. 1.6. Research Methodology To tackle the research questions, this study integrates different theories constructing a social psychological framework to be tested. The aim of the study is to understand and identify the factors that influence CS consumption among women in Egypt. This study embraces a positivistic worldview to conduct the current research. Hypotheses are developed in relation to the conceptual framework. Through a quantitative research approach, the data needed to test the hypotheses is gathered using an online questionnaire. The eligible sample of respondents is young and middle-aged Egyptian women. This study employs volunteer sampling (self-selection). The data was gathered just one time, over a period of three months (March, April, and May 2021). Details about the methodological choices of this thesis are further explained in Chapter 4. Table 1 provides a summary of the methodology of this research. Table 1 - Research Methodology Summary Items Design Reason Philosophy Positivism Objective truth is represented in the theories used to develop the research hypotheses. A model is to be developed and investigated by means of a planned research design and unbiased measures by using deductive reasoning Purpose of the research Causal This research establishes cause and effect relationship between variables. Type of investigation Preliminary data analysis, descriptive analysis, measurement model, Structural equation modelling This research helped identify the relationships between the various variables within the proposed model and explain the fitness of the model. Researcher Interference Extent Minimum The researcher did not influence the respondents when answering the questions in the online survey. Sample size 529 respondents Egyptian women Time Horizon Single Cross Sectional Data is gathered one time, over a period of three months (March, April, and May 2021). 9 1.7. Thesis Structure This thesis is divided into seven chapters. The remainder of the thesis is organised as follows. Chapter 1: Introduction and Background This chapter has provided an overview of the current topic and the background of the subject matter. It has explored the nature of the problem, and described the research methodology, researchable question, and objectives, expected contribution of the research, and the research plan. Chapter 2: Beauty and Cosmetic Surgery A critical review of previous studies focusing on beauty and CS is provided in this chapter. It revises prior literature concerning the evolution of female beauty standards throughout history. This chapter introduces and explores the concept of CS, and the factors leading to its normalization worldwide. Additionally, it provides a focused view on CS in the Egyptian context including the specific factors affecting its pervasiveness. This chapter’s review of prior studies and literature justifies the need for the current research topic. Chapter 3: Theoretical Background and Hypotheses Development This chapter examines various important theoretical perspectives on body image that could be used to understand attitudes and intentions for CS. Additionally, the chapter revises prior literature concerning the antecedents to CS consumption; investigating the sociocultural context; effects of social media, family, and peer influence, as well as the psychological processes that are associated with CS consumption. Importantly, this chapter addresses the research gap, as well as develops hypotheses for testing the relationships between the key research variables. Chapter 4: Research Methodology The design and structure of the current research is outlined in Chapter 4. It clarifies and rationalises the research philosophy, research approach (causal and deductive), research strategy (quantitative researchbased), and data collection techniques (online questionnaire) to be adopted in the empirical collection of data for this study. Details on sampling procedures are provided. Moreover, this chapter discusses the framework of data analysis. 10 Chapter 5: Data Analysis and Results The findings from the empirical study of the data collected for the purpose of data analysis are reported. The outcomes of the analysis are illustrated. In addition, the testing of the hypotheses proposed, and the results of the structural equation modelling are presented. Chapter 6: Research Discussion The findings of this research are examined and discussed in order to further understand their meaning and relevance. A comparison of the empirical findings against the results of prior studies in the literature review also takes places. Chapter 7: Conclusion and Recommendations The overall aim and specific objectives of the current research study are revisited and discussed in terms of how they were addressed. Based on the outcomes of this study, several significant theoretical contributions and managerial implications are presented. This chapter also highlights the research limitations and considers potential paths for future research. 11 CHAPTER 2 - BEAUTY AND COSMETIC SURGERY 2.1. Overview This chapter presents the study’s background by addressing female beauty, its perception and value in society, and the evolution of female beauty standards throughout history. The chapter expands on sociocultural perspectives, and universal standards of beauty dominated by the west. It later discusses cosmetic surgery and the factors leading to its prevalence and normalization in contemporary society. Finally, a focused view on cosmetic surgery in Egypt is provided, including the specific factors affecting its pervasiveness in the Egyptian society. Figure 2 illustrates the chapter’s outline. 2.2. Beauty and Society Human fascination with physical appearance can be traced back thousands of years, demonstrated in mythology, fairy tales and historical anecdotes (Frith, 2012). We evolved to be highly sensitive to human beauty, its compelling and captivating. From the perspective of evolutionary psychology, beauty is not a cultural construct but is rather a biological adaptation (Tadinac, 2010). There is a biological basis behind determining beauty, the innate need to reproduce drives human beings to be attracted to each other. Thus, beauty standards are simply characteristics of sexual selection and mate choice. From birth, newborns can identify and look longer at attractive faces (Liu et al., 2016; Rumsey & Harcourt, 2005), it seems that our brains are somehow wired towards beauty. Viewing attractive faces activate areas of the brain involved in processing rewarding stimuli, such as the pleasurable hit of dopamine (Engeln, 2017). However, sociologists believe in the power of cultural influence with regards to human notions of beauty. From a sociocultural perspective, norms of beauty are socially constructed, anyone who wishes to be Beauty & Cosmetic Surgery 2.1 Overview 2.2 Beauty and Society 2.3 Cosmetic Surgery 2.4 Cosmetic Surgery in Egypt 2.5 Conclusion Figure 2 - Chapter Two Outline 18 media influences (Englis, Solomon & Ashmore, 1994; Frith, Shaw & Cheng, 2005). Stice and Shaw (1994) argue that a sociocultural female ideal is communicated to women, with mass media being ‘one of the strongest transmitters of this pressure’ (p. 289). Along with the media, researchers have found that other institutions aid in the creation of the beauty ideal through peers, friends, and family members (McCabe & Ricciardelli, 2005). In the next chapter, we will discuss sociocultural theory, and how beauty ideals are transmitted through society in more details. Different cultures tend to have different preferences and interpretations about standards of beauty (e.g.., Zhang, 2012). Also, the physical features of Westerners/Caucasians are different than that of the nonWesterners (Yan & Bissell, 2014). In many traditional non-Western cultures (e.g., Korea, China, Japan, and Egypt), plumpness and overweight were seen as beautiful and healthy and represented abundance (Jung & Forbes, 2006). Furthermore, different cultures have different preferences regarding complexion. In many contemporary western societies tanned and bronzed skin is linked to health, status, and beauty (Garvin & Wilson, 1999). On the contrary, Asian, and African cultures favour a fair or light complexion (Johansson, 1998). In traditional Egypt, having fair-coloured skin was associated with high social class, youthfulness, and femininity, while having dark skin was indicative of a lower class. Also, the constituent of the ideal face is perceived differently in different ethnic and cultural backgrounds, as anthropologists argue that the aesthetics of the face are the aesthetics of the race (Gilman, 1999). For example, in traditional Chinese beauty, the obliquity and slimness of the eye was emphasized to exhibit beauty and proper ancestry. Additionally, the construct of beauty is based upon different terms, for example, U.S suggest that beauty is constructed in terms of the body, while in Asian cultures the defining factor of beauty is the face, i.e., Singapore and Taiwan (Frith, Shaw & Cheng, 2005). In conclusion, a lot of crosscultural studies argues that there could not be a singular representation of beauty in cultural and social contexts (Craig, 2006). 2.2.3. The Westernization and Universality of Beauty Contrary to the sociocultural perspective, recent work suggests that the constituents of beauty are neither arbitrary nor culture bound. Considerable research suggests cross-cultural agreement on standards of beauty (Calogero, Boroughs, & Thompson, 2007). This is due to the improved communication technology which has led to an increasing level of global integration between cultures (Desai, 2002). Beauty and physical attractiveness are not resistant to the pervasive trend of globalization. Before the age of globalization, different cultures had their own ideas about what makes one beautiful. As Isa and Kramer (2003) puts it “traditionally, what exactly constitutes beauty has always been a locally indigenous 19 evaluation, this fact is changing across the world” (p. 41). With the expansion of globalization in the modern era, ideas from individual cultures are more easily able to spread to other parts of the world. Hence, a phenomenon of cultural assimilation has occurred where local cultures are being integrated into a universal standard of beauty dominated by western standards of beauty (Isa & Kramer, 2003). It is undeniable that globalization has a great impact on the homogenization of beauty ideals and practices. As Jones (2011) suggests “throughout the waves of globalization, western beauty standards were globalized, and non-western countries local ideals and practices retreated albeit at different rates and to different extent” (p.893). The reason is that the growth of the beauty and fashion industry originates in the West, with all the conglomerates and multinationals, the appeal of celebrity culture in Hollywood and other drivers of an international consumer culture (Jones, 2011). Western and American beauty ideals continue to modern beauty standards due to the influence it holds on to the rest of the world. Hence, beauty ideals, assumptions, and routines prevalent in the west spread as global benchmarks, including small nose, paler skin, long hair, big breasts, and thin bodies (Jones, 2011). These ideals included the aspirational status of France and in particular Paris, as the symbolic capital of beauty and fashion, joined later by New York with the international spread and appeal of Hollywood. Nonwesterners have learned to aspire to western beauty ideals, which led to a worldwide homogenization of beauty standards (Chen et al., 2020). Media and advertising played a pivotal role in diffusing a Western orchestrated beauty. Western media content permeates societies and cultures worldwide, transmitting norms about beauty and appearance via mediated content. The saturation of mass media with images of beautiful women and perfect bodies is akin to a ‘cultural steamroller’, creating and reinforcing a uniform look that is driven by a westerncentric standard (Isa & Kramer, 2003, p.41). In other words, mass media ensured the perpetuation of standardised beauty ideals, and the homogenisation of Western culture (Calogero, Boroughs, & Thompson, 2007). Virtually every form of media exposes individual to information about ideal female beauty (Levine & Harrison, 2004), including magazines (Englis, Solomon & Ashmore, 1994), TV shows (Harrison & Cantor, 1997), TV advertisements (Richins, 1991), music television (Tiggemann & Slater, 2004), popular films (Silverstein et al., 1986), children’s fairy tales (Baker-Sperry & Grauerholz, 2003), and of course newer forms of media such as internet-based social networking sites (e.g., Facebook, Instagram, Pinterest) (Verrastro et al., 2020; Hendrickse, Arpan, Clayton & Ridgway, 2017; Fardouly &Vartanian, 2015; Meier & Gray, 2014). Western media content helped emerge a monoculture and a more critical assessment of non-westernappearing people. Westernized ideals have eroded national beauty standards in many countries (i.e., 20 Asian countries) where cues for modern conceptions of beauty are being drawn from the West (CoyDibley, 2016; Inceoglu & Kar, 2009; Isa & Kramer, 2003). Western culture has created a concept of beauty that is defined by thinness and white skin, which is internalized by many cultures (Murray & Price, 2011). Whereas the ideal image of an attractive women in South Korea was average or slightly overweight figure, more recently women with thinner figures are rated as more attractive (Bissell & Chung, 2009; Jung & Lee, 2006). Similarly, the preference and valuing of white or light skin as a stereotypical feature of the West. In many cultures, white skin is depicted as a notion of beauty and having white skin hold higher status than darker skin (Li, Min & Belk, 2008). Hence, the act of skin bleaching by darker skinned populations is common in Africa to adhere to the white standard. Also, the recent rapid growth in skin whitening creams and lightening products can be attributed to both media and global cultural reinforcement of the European beauty image (Ashikari, 2005). Image editing technology has facilitated standardising the perception of female beauty. Photo-editing applications (e.g., Face Tune, Perfect365, Snapseed) and social media platforms have a photo editing tool (e.g., Instagram and Snapchat) that modify the virtual appearance of an individual. “These applications sculpt the body’s image into virtual proportions based on society’s-imposed standards of unattainable, unrealistic, and specific types of feminine aesthetics (often narrowly modelled on stereotypical, white, slim, able-bodied Westernized aesthetics), which saturate today’s culture” (CoyDibley, 2016, p.2). These apps skewed what is considered a normal body and redefined beauty standards through the merge of diversity into a single look. Women are immersed in editing and altering their appearance using these apps to uphold to social media standards of homogenized and standardised beauty. This has resulted in “digitised dysmorphia” which is the discrepancy between ideal beauty standard imposed by social media and the real appearance of women (Coy-Dibley, 2016). One of the popular social networking apps which created a stereotype of beauty is Instagram (Evens et al., 2021; Verrastro et al., 2020). Instagram introduced beauty filters which normalize the possibility of manipulating photos; allowing users to smooth out their skin, whiten the skin, enhance lips and eyes, contour the nose, alter their jawline and cheekbones, etc. (Chua & Chang, 2016). These filters are used by celebrities and digital creators or influencers; people who have become famous on Instagram and influence behaviours (Glucksman, 2017; Khamis, Ang, & Welling, 2017). Since celebrities and influencers are seen as what’s considered attractive in society, hence, a lot of women seek hiding their imperfections and fitting into this homogenized expression of beauty. Another extreme illustration of the pervasiveness of western beauty standards is the practice of cosmetic surgery. The normalization and popularization of cosmetic surgery could more narrowly define acceptable 21 physical features, create a culture of people who look increasingly similar, and generate little tolerance for ethnic differences. The practice of cosmetic surgery is seen as the result of western ‘harmful’ cultural practices (Aquino & Steinkamp, 2016; Raisborough, 2007). Ethno-altering or changing one's ethnic appearance to mimic the prevalent features of the dominant group has been made possible with the technological advances of surgery; for Asians the most popular cosmetic alteration is eyelid surgery to westernise the look of the eyes (Rainwater-McClure, Reed & Kramer, 2003). For Africans, the skin bleaching and the alteration of noses, and lips (Hunter, 2011). The most sought-after cosmetic surgery in Iran is nose reshaping to attain small-pointed nose, informed by images of the West (Lenehan, 2011). Likewise, cosmetic surgery has been deeply embedded in Middle Eastern cultures (e.g., UAE, Lebanon, Egypt, and Iran) following the emergence of internet-based social media where conventional Western beauty is presented. UAE and Egypt are well known for procedures like body contouring, liposuction, and tummy tucks to attain thin beauty ideals propagated by the west. Some social scientists see plastic surgery as a step towards a modern version of ethnic cleansing for people of colour (Pham, 2014). To conclude, we seem to be gravitating towards a standardised beauty culture, where ideals of beauty are the same worldwide, and often dictated by the West. As Coy-Dibley (2016) posits “the often standardised, homogenized, conventionally attractive, feminized body in Western society’s current beauty culture has become a display piece, performing the culturally inscribed normative standards in order to be deemed an acceptable body” (p.8). In other words, Western beauty emerged as a global ideal, as it pressures women and girls to conform to a fair-skinned, youthful, thin, toned and physically good-looking (Calogero, Boroughs, & Thompson, 2007). In this study, we take the view that, with globalization, the effect of social media, and the popularization and accessibility of cosmetic procedures, societies are moving toward the homogenization of beauty. Moreover, cosmetic surgery promotes new technologies that normalize and homogenize a single ideal standard of beauty. Davies and Han (2011) even argue that this ideal standard is not necessarily Western or Caucasian but rather a cross-cultural standard, it is more of a scientific ideal such as the ‘Golden Ratio’ (p.152), which is a mathematical symmetry algorithm that underlies perception of beauty. In the following section we will delve more into cosmetic surgery consumption as a feminine practice, discuss the different types of cosmetic surgery, the prevalence and normalization of these procedures and lastly discuss cosmetic surgery in Egypt. 22 2.3. Cosmetic Surgery The terms “plastic”, “cosmetic”, “reconstructive” and “aesthetic” are used somewhat interchangeably to describe cosmetic surgery. Plastic surgery ‘covers the entire field’. The term plastic surgery derives from the Greek plastikē, to sculpt or mould (Haiken, 2000). A reconstructive surgery aims to restore normality, by repairing any deformity due to disease, congenital defect, accident, or burn. Cosmetic or aesthetic surgery, by contrast, aims to improve the aesthetic appearance, both terms could be used interchangeably (Shiffman, 2013). There is currently no internationally accepted definition of Cosmetic surgery (CS). The UK Cosmetic Surgery Inter-Specialty Committee has defined CS as an area of practice involving “Operations and other procedures that revise or change the appearance, colour, texture, structure, or position of bodily features, which most would consider otherwise to be within the broad range of ‘normal’ for that person” (Khoo, 2009, p. 237). The American Board of Cosmetic Surgery has defined CS as “a subspeciality of medicine and surgery that uniquely restricts itself to the enhancement of appearance through surgical and medical techniques. It is specifically concerned with maintaining normal appearance, restoring it, or enhancing it beyond the average level toward some aesthetic ideal” (Goh, 2009). CS is a branch of plastic surgery, which aims to enhance the physical appearance of one’s body part(s) using surgical techniques (e.g., rhinoplasty) and non-surgical techniques (e.g., filler treatments) (Furnham & Levitas, 2012). A distinguishing feature of CS is that it’s elective while reconstructive surgery is not considered elective and usually originates within the physical need of the patient; an underlying birth disorder, trauma, or burn. Hence, reconstructive surgery is an attempt to return to normal, while CS is an attempt to surpass the normal. The definition of the scope of cosmetic or aesthetic surgery concerns itself with the idea that this surgery is chiefly performed on the face and neck, and then to a much lesser degree on the breast region, and finally to an even smaller degree on the abdomen, buttock, and thigh regions (Rogers, 1976). This research will deal largely with CS which consists of procedures that are not related to birth defects, disease, or injury. Procedures conducted on bodies that are generally accepted as undamaged except by time and age, and specifically on the facial region for several reasons. First, research on physical attractiveness focused on person perception that is, on how attractive people are viewed by others. From this perspective, the face is more important than the body because the face is initially a more salient source of information, and facial features are important for social attributions and interactions (Marcikowska & Holzleitner, 2020; Todorov et al., 2015). Attractiveness of a face plays an important role in many aspects of social life. People with attractive faces usually receive higher-level of social 23 acceptance, possess more positive personalities, receive preferential employment and professional advancement, and attain better outcomes in real life situations (Lui et al., 2016; Rhodes & Haxby, 2011). Also, research revealed that social ratings of overall attractiveness were largely determined by facial attractiveness (Ebner et al., 2018). Thus, there appeared to be a compelling reason to focus on establishing the effects of facial attractiveness on the consumption of cosmetic procedures. In the following section we will discuss different types of CS and its taxonomy or categorization into surgical and non-surgical or minimally invasive procedures. 2.3.1. Types of Cosmetic Surgery CS can include a variety of procedures ranging from relatively simple and minimally invasive procedures such as laser hair removal and chemical peels to more complicated and invasive surgical procedures which include augmentations (of the breasts, calves, or buttocks), reductions (of the breasts, nose, or of body fat with the use of liposuction) and reconstruction (of the face or any other body part). These procedures are potentially dangerous and is either irreversible, or reversible only with further surgical intervention. According to the American Society of Plastic Surgeons (ASPS) CS can be categorized into cosmetic surgical procedures and minimally invasive procedures as seen in Table 2. Cosmetic surgical procedures include numerous procedures which can be classified to breast surgery, body lifts, fat reduction, and face and neck procedures (ASPS, 2022). Breast surgery involves using breast implants or fat transfer to increase the size of your breast (breast augmentation), raising, and firming the breast (breast lift), removing excess fat, tissue, and skin to achieve a breast size that is in proportion with the body (breast reduction), and removing breast implants (breast implant removal). Body lifts improve and define certain areas of the body. For example, improving the contour, size, and shape of the buttocks (buttocks enhancement), removing excess fat and skin and restore abdominal muscles (tummy tuck), reshaping the thighs by reducing excess skin and fat (thigh lift), reducing excess sagging skin, and defining the shape of the upper arm (arm lift), and removing excess sagging skin and fat from the body hence having a better proportioned appearance with smoother contours (body contouring). Fat reduction procedures slim and reshape specific areas of the body by removing excess fat deposits and improving body contours and proportion (e.g., liposuction). Face and neck lifts which elevates the skin and tightens the underlying tissues and muscles of the face. For example, reshaping the chin either by enhancement with an implant or with reduction surgery on the bone (chin surgery), adding volume or lifting the cheek (cheek enhancement), improving the shape, position, or proportion of the ear (ear surgery), improving the appearance of eyelids (eyelid surgery), reshaping the nose (rhinoplasty), reducing 24 the wrinkle lines across the forehead or the bridge of the nose between the eyes (browlift), improving visible signs of aging in the jawline and neck (neck lift), enhancing the physical structure of the face with implants (facial implants) and hair restoration procedures. Minimally invasive procedures refer to any surgical procedure that is performed through minimal small incisions instead of a large opening. Minimally invasive can be thought of as less trauma or stress to the body, it is considered safer than open surgery as the body recovers more quickly. Minimally invasive cosmetic procedures are mainly designed to rejuvenate the ageing face and maintain a youthful appearance. There are numerous minimally invasive procedures, the most popular procedure is Botulinum toxin (Botox), which rejuvenates the ageing face by reducing hyperkinetic lines associated with muscles of facial expression to eliminate wrinkles (Sarwer, 2019). Dermal fillers which restore facial volume, fullness, and smoothness particularly of the lower face that is lost with age. Chemical peels which improve the texture and tone of skin by removing the damaged outer layers. Skin rejuvenation and resurfacing that include different treatment modalities to treat the different aspects of skin damage (acne scars, pigmentation, sunspots, or visible blood vessels). Microdermabrasion which uses minimally abrasive instrument to gently sand the skin, removing the thicker, uneven outer layer and has many benefits. Also, there are other procedures like laser hair removal, laser skin resurfacing and tattoo removal (ASPS, 2022; Wollina & Goldman, 2011). The table below (Table 2) classifies CS into two broad categories: cosmetic surgical procedures and minimally invasive procedures according to American Society of Plastic Surgeons (ASPS, 2022) and explains each procedure briefly. Table 2 - Types of Cosmetic Procedures Cosmetic Surgical Procedures Breast Surgery Breast Augmentation (Mammaplasty) A procedure that involves using breast implants or fat transfer to increase the size of your breast Breast Implant Removal A procedure that removes breast implants from breast augmentation or reconstruction Breast Lift (Mastopexy) A procedure that raises and firms the breasts by removing excess skin and tightening the surrounding tissue to reshape and support the new breast contour Breast Reduction A procedure to remove excess breast fat, glandular tissue, and skin to achieve a breast size more in proportion with your body and to alleviate the discomfort associated with excessively large breasts 25 Table 2 continuation Body Lifts Buttock Enhancement Buttock augmentation improves the contour, size and/or shape of the buttocks. This is done with buttock implants, fat grafting or sometimes a combination of the two. Buttock lift improves the shape and tone of the underlying tissue that supports skin and fat in the buttocks area Tummy Tuck (Abdominoplasty) A procedure that removes excess fat and skin and restores weakened or abdominal muscles creating an abdominal profile that is smoother and firmer Thigh Lift A procedure that reshapes the thighs by reducing excess skin and fat, resulting in smoother skin and better-proportioned contours of the thighs and lower body Arm Lift (Brachioplasty) A procedure that reduces excess sagging skin that droops downwards, and tightens and smoothes the underlying supportive tissue that defines the shape of the upper arm Body Contouring A procedure that removes excess sagging skin and fat having a better proportioned appearance with smoother contours Face and Neck Chin Surgery (Mentoplasty) A surgical procedure to reshape the chin either by enhancement with an implant or with reduction surgery on the bone Cheek Augmentation A surgical procedure that adds volume or lift the cheeks Ear Surgery (Otoplasty) A surgical procedure that improves the shape, position, or proportion of the ear Eyelid Surgery (Blepharoplasty) A surgical procedure that improves the appearance of eyelids (upper and lower) Nose Reshaping (Rhinoplasty) A surgical procedure that reshapes the nose to enhance facial harmony Facelift (Rhytidectomy) A surgical procedure that improves visible signs of aging in the face and neck such as sagging, in skin, fold lines, jowls in the cheeks and jaw, loose skin under chin (double chin) Brow Lift (Forehead lift) A surgical procedure that reduces the wrinkle lines across the forehead or the bridge of the nose between the eyes, improves frown lines (the vertical creases that develop between eyebrows) Neck Lift A surgical procedure that improves visible signs of aging in the jawline and neck Thread Lift A procedure that uses absorbable, barbed sutures to offer a tighter, more youthful aesthetic appearance to the face and neck Facial Implants Are specially formed solid materials compatible with human tissues, designed to enhance or augment the physical structure of your face Hair Replacement (Surgical hair transplants) Transplant techniques for more modest change include punch grafts, mini-grafts, micro-grafts, slit grafts, and strip grafts Techniques for more dramatic change include flaps, tissue-expansion, and scalp-reduction 26 Table 2 continuation Fat Reduction Liposuction (Lipoplasty) A procedure that slims and reshapes specific areas of the body by removing excess fat deposits and improving body contours and proportion Cosmetic Minimally Invasive Procedures Botox (Botulinum Toxin) A popular injectable that temporary reduces or eliminates facial lines and wrinkles Dermal Fillers Help to diminish facial lines and restore volume and fullness in the face Chemical Peel Chemical solutions to improve the texture and tone of skin by removing the damaged outer layers Laser Hair Removal Non-invasive technique that uses highly concentrated light to penetrate and damage the hair follicles Laser Skin Resurfacing Also known as a laser peel, or Lasabrasion which reduces facial wrinkles, scars, and blemishes Microdermabrasion Use of a minimally abrasive instrument to gently sand the skin, removing the thicker, uneven outer layer and has many benefits Spider Vein Treatment (Sclerotherapy) Involves the injection of a solution into each affected vein, causing the vein to collapse and fade Dermabrasion Dermabrasion and dermaplaning help to "refinish" the skin's top layers through a method of controlled surgical scraping. The treatments soften the sharp edges of surface irregularities, giving the skin a smoother appearance Skin Rejuvenation and Resurfacing Different treatment modalities are available to treat the different aspects of skin damage (acne scars, pigmentation, sunspots, or visible blood vessels) Tattoo Removal Laser treatments that work on the ink particles in the skin to fragment them so that it could be cleared by the body Source: American Society of Plastic Surgeons (ASPS, 2022) 2.3.2. Cosmetic Surgery as a Feminine Practice The conceptualization of beauty as an innate and a fixed trait (Langlois et al. 2000), has changed in recent decades, and the elective alteration of the body and face has become common place (Sun, 2021). Body modification encompasses a diverse spectrum of procedures, practices, and interventions, ranging from the purely cosmetic to the religiously or culturally prescribed, and from the minimally invasive to the highly transformative. Body modification practices are generally elective, and tend to be driven by aesthetic, cultural, religious, or symbolic considerations. CS is currently located, and marketed, at the end of this continuum of bodily modifications, it is normalized yet another practice of ‘doing respectable femininity in the everyday’ (Raisborough, 2007, p.28). It is undertaken either as a mode of "enhancement" or "normalization." As a mode of enhancement, surgery is meant to improve on the 27 normative body, and women who undergo surgery for this reason typically do so to appear younger or more attractive. As a mode of normalization, surgery is meant to correct the body that purportedly deviates from what is the norm, and women who undergo it do so to appear more normal and conform to societal ideals of attractiveness (Sun, 2021; Vaughan‐Turnbull & Lewis, 2015; Kwan & Trautner 2009). This practice exhibits a clear gendered dimension in two respects. First, women are significantly more likely to undergo CS than men. Second, most cosmetic surgeons are males. This gender disparity is an important focus of debate among feminists concerned with this practice, who work to explain why women are disproportionately compelled to pursue CS in the first place, and how certain qualities of medicine in general, and CS, might be associated with normative masculinity. Before CS gained mainstream approval, the practice was initially developed and reserved for soldiers with severe injuries during wartime to restore their physical appearance (Gilman & Peters, 1999; Haiken, 1997). However, researchers have documented the striking and persistent gender difference in the consumption of cosmetic procedures, as well as interest in having it in the future (Brown et al., 2007). CS rates are increasing for men; yet women continuously outnumber men in the patient population and hence it is mainly the domain for women (Karazsia, Murnen & Tylka, 2017; Markey & Markey, 2010). The gendered rise of CS is confirmed by statistics. For example, the American Society of Plastic Surgeons (ASPS) reports that in 2020, 13.5 million cosmetic procedures (surgical and minimally invasive) were performed in the U.S, where 92% of cosmetic procedures in were undertaken by women. With the most common surgical procedure for women is nose reshaping and the most common minimally invasive procedure is Botox. It is also the case that CS has become increasingly popular among young women (Walker et al., 2019). From the perspective of many feminists, the gendered rise in cosmetic surgery could be explained by women’s adherence to the rigid requirements of normative morphological femininity to which they know their happiness and success is tied to. Bodily dissatisfaction is a fundamentally feminine trait, and that, whereas it is natural for a woman to be dissatisfied with her body (Davis, 2013). Hence, CS is an appropriate and acceptable method of alleviating women’s body dissatisfaction. It is also explained as a function of the greater sociocultural pressure on girls and women for physical attractiveness (e.g., Bartky, 1990; Wolf, 1991; Wertheim, Paxton, Schutz & Muir, 1997). Women and girls are socialized to attend to and enhance their physical appearance and are evaluated by others based on their attractiveness. Compared to men, women spend much more time attending to their bodies, and engaging in beauty practices designed to improve their appearance. For example, skin care regimens, hair styling and colouring, trends in make-up, contouring and highlighting facial features 34 society’s norms of beauty. Consequently, women are more likely to feel pressure to improve their physical appearance and pursue CS to conform to society’s beauty ideal. 2.4.2. Patriarchy The origins of women’s appearance obsession or the beauty myth has nothing to do with women and everything to do with the masculine institution and power (Wolf, 1991, p.13). Beauty standards are no longer an aesthetic interest but an instrument of power, that is set by males, and adopted and practiced by females (Davis, 2013; Bartky, 1990). Women’s submission to the patriarchal system is expressed in their ceaseless staring at their reflection in the mirror, censorship of what they eat, and heightened selfconsciousness. Women modify their bodies in order to live up to male standards, dominated by the expectations of a patriarchal society as a surveillance instrument. As predicted by feminist theory, beauty practices such as CS arose due to pressures that women face in male-dominated societies (e.g., Bartky, 1990; Bordo, 1993). It appears to be that individuals who endorse patriarchal attitudes and beliefs, may be more likely to view CS as an acceptable and ‘‘normalized’’ means of appearance-enhancement (Swami et al., 2013). Patriarchy is a social and ideological system which considers men superior to women (Maktabi & Lia, 2017; Walby, 1996). The patriarchal norms, rules, and practices have deep roots in the Mena (Middle East & North Africa) region (Maktabi & Lia, 2017). The patriarchy imposes masculinity and femininity character stereotypes in society and strengthen the unjust power relations between men and women. Patriarchy is deeply embedded within the Egyptian culture and compounded by interpretation of religious references, which is important in the Arab world. In Egypt, women are dependent on men in every walk of life (e.g., father or husband), and usually retain membership in their father kin group who takes authority and responsibility for them throughout their life until getting married where their husband takes that role (Maktabi & Lia, 2017). Patriarchy permeates Egyptian society at many levels, not only prevails at a household/family level. For example, the beauty and fashion industry including big firms, controlled by men, successfully sell their concept of what is normal and what is abnormal, and peg their stock prices based on women’s insecurities. This whole industry is built on western patriarchal beauty standards, that equates women’s self-worth to their physical appearance. Hence, Egyptian girls grow up with insecurities about their appearances and internalize the idea that they need to be beautiful, and that beauty comprises of certain set of rules dictated by the society. They see beauty everywhere that conforms to the strict standard set by the society, so women start believing that they must stick to these standards or else they will be ugly. 35 Hence, more and more women are opting for CS. If we explore the origins of current beauty standards, we will find that the reason women change and modify their appearance is an internalized patriarchal prejudice. Consequently, CS is a form of patriarchal subjugation (Gimlin, 2000). 2.4.3. Marital Pressure A growing literature documents the importance of physical attractiveness in romantic relationships. Research has documented a “love premium” for beauty whereby physically attractive people are more likely to be in marital and sexual relationships. (e.g., Weitzman & Conley, 2014; Lee, 2009). In Arab culture and Islam, marriage is the only acceptable venue for sexual relations with a romantic partner (Sherif-Trask, 2003). Hence, marriage is really important and sacralised. In Egypt, arranged marriages are common, women resort to this type of marriage if they have not met a partner in their circle of acquaintanceship. Therefore, when it is time for a young man to get married, the process of investigation for potential brides will take into consideration girls’ physical beauty. As such, men usually look for a young, beautiful, fair skinned and thin women. Therefore, being beautiful and conforming to society’s beauty standards improve women’s prospects for marriage. One of the ramifications of patriarchal society in Egypt is the power of masculine gaze, and the establishment of the perceived concept that women and their bodies are used to satisfy the male fantasy and desire. Accordingly, women and girls are subject to sexual objectification, whereby they are treated as body or collection of body parts for sexual use (Bartky, 1990). Women are living under the male gaze, and their value as a female is reduced to how it appeals to the male viewer and/or feed his sexual interest. The influence of the male gaze seeps into female self-perception and self-esteem early at a young age. Consequently, women place great emphasis on their physical characteristics, to attract a potential mate or a marriage prospect (Dixson, Grimshaw, Linklater & Dixson, 2010). Moreover, marriage patterns in Egypt have changed, while the typical timing of marriage for women was teens or early 20s, in recent decades, women are marrying later (some in their late 20s or early 30s), and some women are not marrying at all. Hence, society places pressure on women to attain certain standards of beauty to stand a better opportunity for marriage. Accordingly, plastic surgery is considered one route to attain beauty ideals and have higher chances at getting married. Many Egyptian women opt for CS to follow the norm that shapes the perceptions and desires of potential partners and improve their prospects in marriage (Mikhail, 2010). 36 2.4.4. Western and Islamic Influence Western values and principles contradict with Islamic ones; however, both have significant impact on Arab societies. The Arab Middle Eastern culture is heavily influenced by Islam, and Islamic values have a significant impact on what can and cannot be viewed as acceptable behaviour in society (Kalliny et al. 2008). It may seem natural that CS should be perceived as permissible, and in our modern liberal age, it seems strange to attempt justifying certain surgical acts in the light of a particular cultural or religious tradition (Atiyeh et al., 2008). In Islam, mutilation of one’s body has been clearly prohibited, hence CS performed for the purpose of beautifying oneself is impermissible. The body given to humans is a trust and one is expected to be content with what god has created, and changing the nature created by Allah is a sin (Benari, 2013). On the other hand, multi-national corporations which have originated in the west aided by mass media and advertising have led to the expansion of western ideals of beauty that has become the international standard. Hence, the current surge in CS is the result of the commodified global beauty followed by western civilization, whose focus is the body and its desires (Mckay, Moore & Kubik, 2018; Frith, 2014). The contradicting influence of Islam and the west has resulted in dual pressure on women in Egypt. Muslim women find themselves trapped between Western beauty standards propagated by social media, and religious values and conservatism that are embedded to a great extent in the culture. As a Muslim woman the notions of beauty and self-worth can become something difficult to truly unpack and come to terms with at times. A core concept within Islam is physical requirement of modesty such as covering certain body parts in public, not wearing make-up, with the purpose of not drawing attention to women’s beauty. Hence, CS is thought to be impermissible in Islam. However, a growing number of young consumers are opting for CS in Muslim-majority countries which are governed by conservative Islamic thoughts such as Iran, Egypt, and Saudi Arabia (Bell, 2019; Haris, 2018). The quest for physical perfection and aspiration for Western beauty ideals have a great impact on Arab women. Being immersed in beauty images of models and influencers sharing videos of their procedures taking place and surgeons showcasing their work through before-and after photos have inevitably led to the spread of CS in Muslim countries (Atiyeh et al., 2008). The line that arises between observing religious dress code and aspiring towards mainstream beauty standards is blurred, it seems contradictory or hypocritical to many people, but it seems to be a legitimate shared experience for many Muslim women. For example, you can notice Egyptian women with full hijab with identical pinched noses and plumped pouting lips. Also, non-veiled Muslim women residing to non-invasive procedures, as it does not cause a major change in God’s creation, and thus reconciles opposing pressures. Hence, the influence of the 37 west has led Arab women to indulge in beautification and reshaping of their bodies, unnecessarily changing what God has created (Al-Ghazal, 2007). 2.5. Conclusion CS has seen a significant increase globally; this is equally noticeable in the Middle East and specifically in Egypt. Albeit the Islamic values interwoven in the Egyptian population’s fabric guide against CS, it did not deter its prevalence and commercialisation. This is equally surprising with the financial difficulties experienced by most of the Egyptian people. It seems that the Western influence and its impact on the Egyptian society outweighs all other factors, to a point where females in Egypt would put themselves in harm’s way for their aspirations to conform with western beauty ideals. There are no signs that suggest this is a temporary hype and hence measures are required to make a behavioural shift towards CS. This may include heavier government regulation as well as awareness campaigns through the various media outlets. 38 CHAPTER 3 – THEORETICAL BACKGROUND AND HYPOTHESIS DEVELOPMENT 3.1. Overview The previous chapters have attested the increased importance and value society has placed on feminine beauty as well as the significant surge in cosmetic surgery worldwide. In this chapter, different theoretical perspectives related to body image concerns and body change behaviours are discussed. A social psychological framework is adopted, integrating these theoretical perspectives for understanding the multiple pathways by which women’s body image, and cosmetic surgery attitudes and behaviours are shaped in contemporary society. This chapter is presented in four sections. The first section signifies the current overview of this study. The second section presents the research developments in understanding body image and body change behaviours. It provides deeper insights on different theoretical perspectives namely, sociocultural model (tripartite influence model), social comparison theory, objectification theory, and consumer culture impact model. The third section describes the different antecedents for cosmetic surgery attitudes, such as, sociocultural pressures, psychological processes, materialism, and religiosity. Also, factors associated with cosmetic surgery prediction, with the research hypothesis being developed throughout. Finally, the fourth section provides the conclusion and outlines the research hypotheses. Figure 3 illustrates the chapter’s outline. Figure 3 - Theoretical Background and Hypotheses Development Outline 39 3.2. Theoretical Perspectives on Body Image The concept of body image has been the subject of numerous approaches coming from psychology, sociology, and gender studies. Psychologists are concerned with one’s body-related self-perceptions and self-attitudes including thoughts, feelings, and behaviours (e.g., Ramos et al., 2019; Tiwari & Kumar, 2015). Sociologists are particularly interested in understanding how body image is culturally and socially constructed and shaped (e.g., Grogan, 2021; Jacobs, 2003). Gender studies are concerned with gender differences in body image and how these differences manifest themselves in men and women. Body image concept has been constructed, from psychological and sociological perspectives with a gendered perspective. To explain body image, we need to recognize the interplay between the experiences of individuals in relation to their bodies, and the cultural and social environment in which the individual operates (Grogan, 2021). Moreover, gender is a salient factor in body image development (Cash & Pruzinsky, 1990). Women are more cognitively and behaviourally invested in their appearance (Cash & Hicks, 1990). Body dissatisfaction and eating disorders are particularly common among women (KeskiRahkonen & Mustelin, 2016; Karazsia, Murnen & Tylka, 2017). Furthermore, women are more likely to engage in appearance modifying behaviours (e.g., cosmetic surgery; Sinno et al., 2016). Thus, body image research has mainly focused on women (Quittkat et al., 2019). Body image is a multidimensional, self-attitude towards one’s body, particularly its appearance (Cash & Pruzinsky, 1990). Thus, it refers to how people think, feel, and behave towards their physical traits. Body image encompasses perceptual, attitudinal, and behavioural aspects of the body (Cash & Deagle 1997). The perceptual component of body image refers to how the mind senses and perceives the body and is characterized by the accuracy by which individuals estimate their body size (Neagu, 2015). Distortion of body size that goes in the direction of overestimation was long time considered a predictor factor in the development of eating disorders. The attitudinal dimension of body image comprises evaluative, affective, and cognitive subcomponents (Muth & Cash, 1997). Body-image evaluation refers to satisfaction or dissatisfaction with one’s physical attributes, as well as evaluative thoughts and beliefs about one’s appearance. These evaluations derive in part from self-perceived discrepancies from internalized physical ideals (Cash & Szymanski, 1995; Strauman & Glenberg, 1994). The affective component refers to discrete emotional experiences that these self-evaluations may elicit in specific situational contexts (Szymanski & Cash, 1995). The third and most distinct attitudinal dimension, cognitive-behavioural investment, is the extent of attentional self-focus on one’s appearance. The behavioural aspect of body image includes actions involving the management and enhancement of appearance (Cash, 1990). 40 Thus, in the following sections, we will discuss different theoretical models related to the development of body image concerns and body change behaviours. First, the Sociocultural Model (Tripartite Influence model), which examines how sociocultural ideals of physical attractiveness and psychological factors interact and influence body image concerns and modifying behaviours. Second, Social Comparison Theory, which justifies women’s appearance-focused social comparisons and their subsequent effects on body image concerns and intentions toward appearance enhancement behaviours. Third, Objectification Theory, which discusses the experiential consequences of being female in a culture that sexually objectifies the female body. Internalizing an observer’s perspective as a primary view of the physical self, bring about a sort of psychic distancing between the self and the body that encourages women to support even further objectification of their bodies via body enhancement procedures. Fourth, Consumer Culture Impact Model, which explains the negative psychological impact of internalising core consumer culture ideals, which in turn affects individuals’ thoughts and behaviours concerning their physical appearance. The applications of these theories and models will be discussed. Furthermore, justification for the chosen theories is offered in order to construct the research framework. 3.2.1. Sociocultural Model (Tripartite Influence Model) One of the dominant theoretical frameworks for the development and maintenance of body image is the sociocultural model (Rodgers, 2016). This model holds sociocultural ideals and pressures as paramount to the genesis of body image disturbance (Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999; Tiggemann, 2012) and recently body change behaviours (Di Gesto et al., 2022; Jackson & Chen, 2015). The model does not deny the importance of individual characteristics, however the focus is on the aspects of the physical environment, as well as the social and cultural practices, norms, beliefs of a society. Sociocultural is best thought of as a conceptual model providing a general framework for understanding contemporary body image. At its most basic, sociocultural theory holds that (1) there exist societal ideals of beauty (within a particular culture) that are (2) transmitted via a variety of sociocultural channels. These ideals are then (3) adopted or internalized by individuals, so that (4) body satisfaction (or dissatisfaction) will be a function of the extent to which individuals do (or do not) meet the ideal prescription. Such satisfaction or dissatisfaction will then have (5) affective and behavioural consequences of its own (e.g., eating disorders). The model also acknowledges the importance of individual characteristics, hence, recognizes that (6) there will be individual differences in response to sociocultural pressures. More formally, there are a variety of biological and psychological characteristics that moderate the links in the model, and ultimately determine an individual’s degree of vulnerability to 41 sociocultural pressures (Tiggemann, 2012, p.759). Figure 4 provides a representation of the whole model. Figure 4 - Schematic representation of (a) general sociocultural model, (b) most applicable and researched specific example, and (c) other possibilities within the sociocultural framework Source: Tiggemann, 2012: p.760 There are different sociocultural models that investigate body image and disordered eating. The most widely tested and well-validated is the Tripartite Influence Model. In its original form it proposes that sociocultural and psychological factors interact and directly influence body image (Thompson et al., 1999). It postulates that appearance pressures for women are transmitted and reinforced through three primary sociocultural sources: the media (e.g., through adverts featuring thin and youthful airbrushed models), parents (e.g., direct criticism or through placing a great value on their appearance), and peers (e.g., through peer pressure regarding appearance). The model proposes two psychological processes through which these sociocultural influences exert their influence on body image: internalisation of appearance ideals (i.e., the degree to which a person cognitively “buys into” socially determined ideals of beauty) and social comparisons regarding appearance (i.e., the degree to which a person compares their own appearance with others regardless of the direction of comparison). Hence it tests direct (peer, parental, and media factors) and mediational links (internalization of societal appearance standards, and appearance comparison processes) as factors potentially leading to body dissatisfaction, eating disturbance, and body change behaviours (Lewis-smith, Diedrichs, Bond & Harcourt, 2020; Carvalho & 42 Ferreira, 2020; Shagar, Donovan, Loxton & Harris, 2019; Huxley, Halliwell & Clarke, 2015; Tiggemann, 2012; Shroff & Thompson, 2006). Even though the tripartite influence model has proved its success to predict body image disturbances and eating disorders, scholars have suggested several limitations to this theoretical model. The claims of this sociocultural model have been investigated in the western world and primarily among white women, nevertheless, the tripartite influence model is especially relevant to non-white populations, since these women may feel pressure to attain western beauty standards (Stojcic, Dong & Ren, 2020). The usefulness of this model in explicating risks for others outside that particular demographic warrants investigation (i.e., different racial and ethnic groups) (Schaefer et al., 2018). Cultural specificities are important factors to consider when devising and analysing sociocultural models of body dissatisfaction (Burke et al., 2021). For instance, family connection and interdependence are central cultural values in collectivistic Arab societies (Dwairy et al., 2006). Therefore, the influence of family on body image maybe particularly salient for Arab women. Hence, this research attempts to consider these cultural specificities in Egyptian women. The influence of other sociocultural agents, such as medical practitioners, sports coaches, and new social media influencers, as well as other situations like fitness and beauty centers need to be studied. Also, newer forms of media such as the internet and new social networking sites should be investigated. Moreover, the sociocultural model has been applied primarily in the realm of body weight and shape, particularly focusing on thin ideals of attractiveness. In principle, however, the perspective applies equally well to other aspects of body image such as facial appearance (e.g., skin colour and texture, size of eyes, shape of nose and lips) (Tiggemann, 2012). Furthermore, there are other messages transmitted by sociocultural influences. For example, alongside the glorification of a thin body comes a very strong antifat message. There is also a parallel idolization of youth and denigration of aging. Hence, there are a corresponding variety of other behavioural responses, ranging from tattooing and tanning to cosmetic surgery. Hence, other increasingly common behaviours such as cosmetic surgery should be investigated more within the theoretical framework of the sociocultural model. Another limitation is that the existing research is primarily correlational and hence cannot determine causality or whether a specific variable is a causal risk factor. For example, in the case of the effects of media, while it is tempting to conclude that exposure to idealized images lead to body dissatisfaction in accord with the causal sequence proposed in the sociocultural model, the converse causal assumption is equally plausible: body dissatisfaction may lead to heightened use of the media. Yet, there is surprisingly little longitudinal evidence indicating that sociocultural influences precede body concerns in time, a necessary condition 43 for causality. In fact, most likely the relationship between sociocultural influences particularly appearancefocused social media engagement and aspects of body image is likely to be bidirectional (Cohen, NewtonJohn &. Slater, 2017; Tiggemann, 2012, p.764). 3.2.2. Social Comparison Theory Social comparison theory (Festinger, 1954) proposes that people have an innate drive to compare certain aspects of themselves to other people so that they have a better assessment of themselves. Social comparison is defined as “the inclination to compare one’s accomplishments, one’s situation, and one’s experiences with those of others” (Buunk & Gibbons 2006, p. 16). The basic premise of the theory is that when objective standards against which one can evaluate his/her attributes are absent, one will instead use social information as a comparison standard (Mangleburg, Doney &Bristol, 2004). Indeed, Festinger (1954) indicated that individuals observe others around them, identify comparison targets within that social context, and compare to them. These comparisons can provide normative information that, in turn, influences how individuals think and feel about themselves (Epstude & Mussweiler, 2009). According to social comparison theory, individuals compare and evaluate themselves as well as others in various domains including appearance and attractiveness. Appearance-focused social comparisons involve comparing qualities of one’s own physical appearance to others such as weight, body size, body shape or overall appearance (Jung & Lee, 2006; Schutz, Paxton, & Wertheim, 2002). Although Festinger (1954) proposed that social comparison was driven by a need to gain accurate selfevaluations, following the initial theory research began to focus on the motivations that underlie social comparisons. Motives that are relevant to social comparison include self-evaluation, self-improvement, and self-enhancement (Tsai, 2013; Krayer, Ingledew & Iphofen, 2008; Buunk & Gibbons, 2007). Selfevaluation comparisons are used to gather information about one’s own standing in relation to similar others (e.g., How does my body compare to my friends?). Self-improvement comparisons are employed to learn how to improve a particular characteristic or for problem solving (e.g., How could I learn from a friend to be more stylish?) (Wood, 1989). Self-enhancement comparisons are employed to make people feel good about themselves and maintain self-esteem. Individuals would distort or ignore the information gained by social comparison to view themselves more positively and further their self-enhancement goals. Individuals can downplay skills that they lack or criticise others to seem better by comparison (e.g., she might look beautiful, but she is arrogant) (Wills, 1981). As a result, directions of social comparisons could be upward, downward, and lateral. Upward social comparisons occur when individuals compare themselves to someone whom they believe to be better off than themselves. Downward social 50 contrived to keep women consuming and consumed. Thus, the fashion-beauty industry is rooted in the capitalist patriarchy (Henderson & Brooks, 2009). In the beauty industry, an objectified view of the female body is promoted to increase the consumption of products and services that increase the value of the body. As Henderson and Brooks (2009) puts it: ‘women’s objectified body consciousness occurs within a larger context that profits from the sale of goods and services designed to meet needs that are created by the system itself” (p.135). In an analysis of contemporary consumer culture, Dittmar (2008) proposes the consumer culture impact model which includes two prominent ideal identities, particularly prevalent in advertising and the media: the “body-perfect” ideal, and the “material good life”. The consumption of goods is marketed as a bridge toward achieving the “body perfect”, the “material good life” and thus an “ideal self” (Dittmar, 2008, p. 2). It has become commonplace that consumer culture is obsessed with the body. The media— magazines, TV, films, and advertising—not only emphasize that female self-worth should be based on appearance but present a powerful cultural ideal of female beauty (Tiggemann, 2012). Correspondingly, new forms of media e.g., social networking sites are preoccupied with perfect bodies and idealized images of celebrities, models, and influencers who promote unrealistic standards that define beauty (Holland & Tiggemann, 2016). Media with its different forms work on the firm establishment in consumers’ minds that their bodies and faces are malleable and can be transformed and enhanced through consumption of commodities (Featherstone, 2010; Felix & Garza, 2012). One of the most dramatic techniques for body construction in consumer culture is cosmetic surgery, which has become legitimated as a popular form of self-improvement (Doyle, 2008; Jones, 2008; Gimlin, 2007). Schouten (1991) referred to cosmetic surgery as particularly dramatic form of symbolic consumption. In consumer culture, people attend to their bodies in an instrumental manner, and the body is viewed as a form of self-expression. Hence, the modification and cosmetic enhancement of the body through a range of regimes and technologies can be used to construct a beautiful appearance and thereby a beautiful self (Featherstone, 2010). The body in contemporary consumer culture serves as another source for consumption. Changing the body is as easy as the consumption of any other commodity available in a consumer society. Bodies no longer have to be damaged or impaired to merit surgical alteration. Growing older, gaining, or losing weight or simply failing to meet the cultural norms of beauty are now reason enough for surgical improvement procedures. Consumer culture ideals of appearance frequently portray unrealistic and unattainable body image and focus on the discrepancy between these ideals and the self. Hence, cosmetic surgery is portrayed as the pathway to repair the body and achieve society’s beauty ideals (Covino, 2004). 51 The “body perfect” is only one ideal identity, the other central element of consumer culture is the “material good life” which emphasizes materialistic pursuits; an affluent lifestyle and social status filled with expensive material goods, possessions, and activities. Dittmar (2008) model of consumer culture proposes that both consumer culture ideals are closely interconnected, since individuals who emphasize their physical appearance develop a similar relationship with their body as materialists with their material possessions. According to Henderson-King & Brooks (2009) “materialist individuals are likely to relate to their bodies as they might relate to other objects” (p. 135). Moreover, perfect appearance and an affluent lifestyle are typically portrayed together especially in social media, and both emphasize symbols of an ideal identity (Grouzet, Kasser, and Ahuvia, 2005). Thus, we can conclude that consumption and materialism are central aspects of contemporary society. The popularization of the consumer culture ideals is built on the fascination with stars, celebrities, and recently social media influencers and content creators who contribute to the symbolic link between material goods and the status of fame, success, and beauty (Ashikali and Dittmar, 2012). Increasingly, ordinary people aspire to achieve this affluent ideal by acquiring material goods as means for enhancing status, and attaining media-hyped appearance ideals (Dittmar, 2007). Therefore, elements of consumer culture, material success and body perfect have a powerful resonance in contemporary societies (Grouzet, Kasser, Ahuvia, 2005). As a result, an individual moves closer from their actual identity to the ideal identity depicted by the media. Thus, consumer culture plays a significant role in constructing beauty norms and ideals, reinforced by the society and culture, which influence individual’s thoughts and behaviours concerning their physical attributes through psychological processes (Dittmar, 2007). In other words, consumer culture does not regulate our thoughts, feelings, and behaviours in a direct way. It rather encourages, and makes more likely, certain patterns of interpretations and behaviours penetrates to the very fabric of our experience and understanding of the world (Dittmar, 2007). Figure 6 proposes this social psychological model following the recommendation of Dittmar (2007). Figure 6 - Social Psychological Model of Consumer Culture Source: Dittmar 2007: p.16 Consumer culture ideals Individual thoughts, feelings, and behaviour Psychological factors and processes 52 3.3. Antecedents of Cosmetic Surgery Attitudes and Behaviours Previous research has identified different factors influencing cosmetic surgery attitudes and behaviours. The body of literature theorizes two broad motives that underpin people’s favourable attitudes towards cosmetic surgery: intrapersonal motives and social motives (Wu, Mulkens and Alleva, 2021; HendersonKing and Henderson-King 2005). Intrapersonal motives emphasize the use of cosmetic surgery to manage one’s self-image, improve feelings of inadequacy, and feel satisfied with oneself (Davis, 1995; Didie & Sarwer, 2003). From this perspective, the individual endorses self-oriented reasons for deciding to undergo cosmetic surgery. Intrapersonal factors include negative body image (Markey & Markey, 2009), appearance-based self-esteem (Delinsky, 2005), and internalized media appearance ideals (Sarwer et al., 2005; Sperry et al., 2009). Social motives emphasize the use of cosmetic surgery to gain favourable evaluations from others (Davis, 1995; Henderson-King & Henderson-King, 2005), based on the notion that enhancing one’s physical attractiveness to others brings social rewards (Eagly, Ashmore, Makhijani, & Longo, 1991; Evans, 2003). Societal factors include appearance-related teasing (Markey & Markey 2009), media and celebrity influence (Wen, 2017), and materialism and parental pressure (Henderson-King & Brooks 2009). From this perspective, an individual endorses social motivations for deciding to have cosmetic surgery. As discussed earlier, physically attractive women receive preferential social treatment in virtually every situation studied, including education, employment, medical care, and partner selection (Wu, Mulkens & Alleva, 2021; Bull & Rumsey 1988). However, we cannot extract the individual from the social context, as the personal concerns about physical appearance and the adherence to social norms of beauty are personalized and internalized (Bartky, 1990). As such, intrapersonal and social motives for cosmetic surgery coexist and interact (Henderson-king & Brooks, 2009). For example, feeling unattractive in the eyes of others could have a negative impact on self-esteem, which in turn might lead to consideration of cosmetic surgery to address one or the other of these concerns or both simultaneously. Hence, both motives are conceptually distinct but it’s difficult to separate them completely. For this reason, this research focuses on the interplay between psychological and social motives for adopting these attitudes and behaviours. Hence, we take the view of cosmetic surgery attitudes as being formed by three specific components: (1) Intrapersonal reasons (internal psychological), (2) Social reasons (3) The actual consideration of cosmetic surgery (Henderson-king & Henderson-king, 2005). This research relies on a social psychological theoretical framework to explain the antecedents for cosmetic surgery consumption as illustrated in Figure 7. This section presents a summary of the results 53 of the main studies and the influences they explored. Throughout Section 2.3.3. in Chapter 2, the normalization of cosmetic surgery was influenced by various elements, including those that are cultural, social, and psychological in nature. As such, the antecedents of cosmetic surgery reviewed in this section are sociocultural pressures (social media, peer, family), and their role in transmitting beauty ideals. The psychological processes associated with cosmetic surgery attitudes, namely, internalization of appearance ideals, appearance comparison, and self-surveillance. The role of consumer culture and materialism in explaining attitudes towards cosmetic surgery. Lastly, the importance of religion in one’s life, and how it affects attitudes towards cosmetic surgery. The following subsections will discuss each variable in detail. Figure 7 illustrates the research framework. Figure 7 - Research Framework 3.3.1. Sociocultural Pressures Socialization is a process through which individuals are taught to assimilate into society and acquire their culture, whereby a person internalizes societal norms, values, and beliefs. It is commonly defined as the: “process by which young people acquire skills, knowledge, and attitudes relevant to their functioning as consumers in the marketplace” (Ward, 1974, p. 1). Humans need social experiences to learn their culture, and socialization is a central influence on the beliefs, behaviors, and actions of people. For example, if the culture puts emphasis on attractiveness in its members, then individuals will value attractiveness in themselves and others. If the culture warns against the importance of attractiveness, then individuals will likewise consider it unimportant in judging themselves and others. In other words, in any culture, an individual physical appearance is constructed by and in response to society’s conventions and expectations. The socialization process takes place through what is known as 54 socialization agents, such as: family, peers, religion, mass media, and other institutes. Family and peer groups are primary agents for socialization. Schools, religious institutions, and mass media are considered as secondary means of socialization (Arnett, 1995). Research on socialization and the impact of these groups on consumer behavior has been taking place for more than 40 years. In body image literature, the impact of socialization agents, specifically among media, peers and family is evident (Lewis-smith et al., 2020; Carvalho & Ferreira, 2020; Shagar et al., 2019; Huxley, Halliwell & Clarke, 2015; Tiggemann, 2012; Shroff & Thompson, 2006). According to social learning theory, humans observe and imitate others (Bandura, 1977; Crain, 2015). People view and replicate cultural norms around beauty. In many cases, these norms involve body modification or cosmetic surgery for women. Therefore, when women observe their peers and members of their own culture undergoing cosmetic surgery, they are more likely to engage in this practice. People are more likely to adopt observed behavior if it appears to have valued outcomes (Bandura, 1977, p. 28). When women observe other women who have had cosmetic surgery reaping positive social outcomes, they are in turn more likely to get cosmetic surgery. Another source of social learning is provided by various media sources, including magazines, television, and films (Bandura, 1977, p. 39). Images of feminine ideals are repetitively displayed throughout all types of media influencing women’s perceptions of beauty. These images can leave women feeling insecure and tempted to undergo cosmetic surgery to achieve the feminine ideal presented in the media. When looking at beauty norms through Bandura’s (1977) social learning theory, one can conclude that body modification and cosmetic surgery are socially and culturally learned. Past studies have highlighted the effect of the sociocultural context on women’s cosmetic surgery attitudes and behaviors. Moreover, according to tripartite influence model explained earlier, appearance pressures for women are transmitted and reinforced through three primary sociocultural sources: media, peers, and parents. Hence this research mainly focuses on the influence of sociocultural influences namely (social media, peer, family, and religion). These socialization groups are to be discussed in the following sections. 3.3.1.1. Social Media Influence In line with tripartite influence model, media has been identified as the primary socialization agent. It is through media that appearance ideals are transmitted (Clark & Tiggemann, 2006; Levine & Harrison, 2009). Mass media created a preoccupation with physical attractiveness through all its different platforms such as television, newspaper, magazines, movies etc. (Ravary, Baldwin & Bartz, 2019). Television programs are saturated with idealized images of women that set unrealistic standards of 55 beauty (Wasylkiw et al., 2009). Magazines feature sexualized images for celebrities and models which reinforce the social value of attractiveness (Sarwer & Crerand, 2004; Henderson-king & Henderson-king, 2005). However, traditional media may no longer exert the sole dominant power that it had before the rise of new forms of media particularly internet-based, social networking sites (SNSs) (Gil de Zúñiga, Jung & Valenzuela, 2012; Meraz, 2009). SNSs are popular social media sites that allow users to create personal profiles of photos, video, audio, and blogs which are made available to friends, followers, or the public (Kaplan & Haenlein, 2010). Social media is continually increasing in popularity and becoming the primary media source used especially by female young adults (Bair et al., 2012; Tiggemann & Slater, 2013). However, little published research to date, has examined whether and how social media use, particularly Instagram, may influence perceptions of physical ideals. Mass media have been implicated as an especially significant source of influence for the perceptions of beauty and the internalization of “body perfect” ideals when girls are at a very early age (Dittmar, 2009). Beginning with young girls’ exposure to mass communicated images of the Barbie doll— “the cultural icon of female beauty” (Dittmar, Halliwell & Ive, 2006, p. 283)—moving developmentally to viewing of television advertisements and programs that glorify ultra-thin models and commencing in adolescence and early adulthood with appearance-focused Facebook conversations, Instagram picture sharing, and fashion-focused tweets (Chrisler et al., 2013). Internalization is defined as the incorporation of specific values to the point that these values become guiding principles (Thompson et al., 2004). Internalization of appearance ideals refers to the extent to which an individual subscribe to socially defined ideals of attractiveness, incorporates these standards into one’s personal belief system and aspires to attain these ideals (Thompson & Stice 2001). It is important to draw a distinction between individuals simply being aware of sociocultural ideals of appearance and individuals internalizing these ideals as their own personal goal, not everyone internalizes those societal standards to the same degree (Stice, 2002). Internalization can be conceptualized as not only the endorsement of the media ideal but also adjustments to one’s behaviour to achieve these standards (Thompson et al., 2004). Theoretically, previous research has focused on thin-ideal internalization to the extent that mediainternalization is frequently referred to as thin-ideal internalization (Rodgers, McLean & Paxton, 2015). In the 1990s the female beauty ideal became synonymous with the ‘thin ideal’ (Owen & Laurel-Seller, 2000). Internalization of thin-ideal refers to the extent to which women attach psychological importance to thinness, cognitively accept the thin societal standard of attractiveness as their own personal standard and engage in behaviours designed to help them meet that thin-ideal (Thompson et al., 1999; Dittmar, Halliwell & Stirling, 2009). The media has espoused a viewpoint that the ultra-slender look is both 56 desirable and achievable; by portraying thin models and emphasizing the perceived benefits of thinness including attractiveness, success, and social acceptance (Brownell, 1991; Thompson et al., 1999). The stronger the internalization of the thin media ideal, the larger the discrepancy between the unattainable media ideal and one’s own physical appearance (Thompson et al., 1999; Stice & Whitenton, 2002). Hence, girls and women who have internalized cultural standards of attractiveness are more vulnerable to experiencing the negative outcomes associated with exposure to beauty ideals than women who have not internalized these ideals. The internalized ideal can become problematic because media content often does not reflect reality propagating incomplete, inaccurate and biased content that becomes the standard against which the self and others are judged (Calogero, Boroughs & Thompson, 2007; Yamamiya et al., 2005). SNSs have the potential to impact the internalization of body image ideals to a greater extent than traditional media because of the characteristics of online information exposure (Mingoia, Hutchinson, Wilson & Gleaves, 2017). The main difference between mass media and SNS is the element of interactivity and connectedness, not only can users create their own personal profiles and post photos, but also can browse the posts of and interact with other users. Media content on SNS are available for viewing, creating, editing and, most importantly, sharing, immediately every moment of every day on a plethora of devices (Perloff, 2014). The constant access is paired with an abundance of content, which creates plentiful of opportunities for the internalization of beauty standards (Mills, Shannon, & Hogue, 2017; Perloff, 2014). Users of social media are exposed online to a broader audience (i.e., celebrities, influencers, peers, and family) simultaneously in a single medium, which may encourage the internalization of body image ideals in a much more profound way than any of these influences in isolation (Slattery, 2013; Meier & Gray, 2014). In accordance with sociocultural models of body image, more recent but growing body of research has demonstrated the impact of SNSs in reinforcing and transmitting beauty ideals, particularly image-based platforms such as Instagram and Facebook (Verrastro, Fontanesi, Liga & Cuzzocrea, 2020; Strubel, Petrie, & Pookulangara, 2018; Fardouly & Vartanian, 2016; Holland & Tiggemann, 2016; de Vries et al., 2014; Perloff, 2014; Ringrose, 2011). Hence, this research will focus on the effect of social media use, particularly Instagram, in transmitting society’s beauty ideals. A body of research suggests a link between SNS use and the internalization of body image ideal (Mingoia et al., 2017; Tiggemmann & Slater, 2013; Fardouly & Vartanian, 2015). The reason is that impression and reputation management are important in the use of SNSs because these sites allow users to manage both their social network as well as their social identity (Riva, Wiederhold & Cipresso, 2016). Subsequently, physical appearance and self-presentation are vital to SNSs (Siibak, 2009), with the most 57 common activities focused on uploading and viewing photographs of others (Espinoza & Juvonen, 2011) that are selected based on appearance (Siibak, 2009). Studies that operationalized the use of SNSs solely as a function of specific appearance-related features (e.g., posting, commenting, or viewing photographs on SNSs) have found stronger associations with an internalized ideal (McLean et al., 2015; Tiggemann & Miller, 2010). Meier and Gray (2014) suggested an association between Facebook usage and the internalization of appearance ideals, they found that elevated appearance exposure on Facebook (e.g., posting, viewing, and commenting on images) leads to thin ideal internalization. Similarly, Mingoia and colleagues (2017) revealed a correlation between exposure to appearance related content on Facebook and the internalization of thin ideal in females. Cohen and colleagues extended Meier and Gray’s (2014) findings, by demonstrating that appearance-focused SNS use (on both Facebook and Instagram) were correlated with thin-ideal internalisation. However, recent research is investigating the use of the primarily photo-based platform, Instagram, given its increasing popularity amongst young women (Cohen, Newton-John & Slater, 2017). Empirical evidence suggests that Instagram plays a significant role in the internalization of appearance ideals (Feltman & Szymanski, 2017; Fardouly, Pinkus & Vartanian, 2017). Instagram creates a strong visualoriented culture (Lee et al., 2015). Its primary use is for posting, sharing images, and engaging in visual self-presentation of one’s actual or ideal self as well as viewing content of others (Fardouly et al., 2017; Harris & Bardey, 2019). It features a few possible filters to enhance or edit the appearance of a photo to achieve an ideal look, which in turn help promote cultural beauty ideals (Sheldon et al., 2017; Holland & Tiggemann, 2016). Studies indicated that Instagram may be more detrimental to women’s appearance concerns than other social media platforms (such as Facebook) that contain more varied content (e.g., Fardouly & Vartanian, 2016; Holland & Tiggemann, 2016). Another unique feature of Instagram is the prominence of “fitspiration” images of women (the term fitspiration is a combination of the words fitness and inspiration). Although the intent of these images is to motivate people towards a healthy lifestyle, they are largely appearance-focused and contain images of thin and toned women (Tiggemann & Zaccardo, 2016), which largely match the current societal beauty ideal (Krane et al., 2001). An additional feature in Instagram worth mentioning is the popularity of cosmetically enhanced females’ images. These images reinforce cultural standards of beauty directly when users observe these women receive attention and positive commentary about their appearance (Walker et al., 2019; de Vries et al., 2014). Correspondingly, Instagram propagates images of feminine ideals, exposure to these idealized representations of women’s physical appearance influence women’s perception of beauty and enhance the salience of the societal beauty ideal, which in turn, may increase the extent to which women 58 internalize that beauty ideal (Fardouly, Willburger and Vartanian, 2018; Feltman & Szymanski, 2018; Vandenbosch & Eggermont, 2012). As such this study focuses on social media (Instagram), we hypothesize that: Appearance comparisons are made in different contexts (e.g., traditional media, social media, and in person) (Fardouly, Pinkus & Vartanian, 2017). Different contexts may contain different appearance comparison targets. Whereas traditional media generally provides women with the opportunity to compare their appearance to models and celebrities, social media contains a variety of known targets (e.g., family, close friends, peers), celebrities, influencers, and strangers (Fardouly, Diedrichs, Vartanian, & Halliwell, 2015b; Fardouly & Vartanian, 2015), and appearance comparisons made in person are likely to be to known others or strangers. Although most research on appearance comparisons has focused on comparisons to idealized images of women in traditional media, particularly magazines (Myers & Crowther, 2009). The popularity of social media among young women is outpacing the popularity of traditional media (Kimbrough, Guadagno, Muscanell, & Dill, 2013). A significant amount of research has found that social media provide women with more opportunities to compare their appearance to others more than on any other media platform (i.e., television, magazines, billboards) (Hendrickse et al., 2017; Fardouly et al, 2017; Fardouly & Vartanian, 2015; Tiggemann & Slater, 2013, 2014; Tiggemann & Miller, 2010). Researchers continue to explore the specific key elements of social media activity that may drive more appearance comparisons (de Vries, Möller, Wieringa, Eigenraam, & Hamelink, 2017; Meier & Gray, 2013; Haferkamp & Krämer, 2011). Social media feeds tend to be preoccupied with images featuring sociocultural beauty ideals, it is frequently curated, posed, filtered, and edited photos of attractive celebrities, influencers, and peers, providing ample opportunities for upward social comparisons (Engeln, Loach, Imundo & Zola, 2020). It might also be partly attributed to the exposure to relevant comparison targets such as peers, in accordance with social comparison theory (Festinger, 1954). Alternatively, images on social media may be more readily accessible than images on traditional media because social media can be easily accessed on mobile phones (Fardouly et al., 2017). Experimental and correlational studies have suggested that the relationship between social media use and body dissatisfaction may be partially mediated by appearance comparisons (Brown & Tiggemann, H1a: Social media influence has a positive effect on internalization of appearance ideals 59 2016; Fardouly & Vartanian, 2016; Feltman & Szymanski, 2018; Hendrickse et al., 2017; Sherlock & Wagstaff, 2019; Tiggemann & Zaccardo, 2015). A body of literature have suggested that Facebook use leads to higher tendency for social comparison (Fardouly & Vartanian, 2015; Kim & Chock, 2015). A study by Haferkamp and colleaugues (2012) implied that exposure to idealized images and profiles on Facebook lead to comparisons with those individuals. In general, comparisons to peers featured prominently in Facebook usage, given that Facebook is primarily used for interacting with peers, who are considered similar and relevant comparison targets (Hew, 2011; Festinger, 1954). Recent research suggests that Instagram use could be potentially harmful to individuals who find themselves frequently engaging in appearance comparisons with others (Hendrickse et al., 2017). A recent experiment by Engeln and colleagues (2020), tested the effects of Facebook and Instagram on women’s appearance comparisons. They found that Instagram users reported significantly more appearance comparisons than those in the Facebook condition. Similarly, Chang, Li, Loh, & Chua, (2019) study, suggested that photo browsing and editing behaviours on Instagram in a sample of Singaporean girls lead to appearance comparisons to peers. It is more common for people to follow and view images of celebrities, models, and influencers on Instagram. Thus, comparisons to these targets might be more prominent on Instagram. Instagram provides users with regular opportunities to compare their appearance to others and judge themselves to be less attractive than others (Tiggemann, Hayden, Brown & Veldhuis, 2018; Feltman & Szymanski, 2017; Myers & Crowther, 2009; Vandenbosch & Eggermont, 2012). Idealized Instagram images elicit upwards appearance comparisons to specific target groups such as women with thin and toned bodies (i.e., fitspiration images) (Fardouly et al., 2017; Simpson & Mazzeo, 2017; Tiggemann & Zaccardo, 2016), women with facial cosmetic enhancements (Walker et al., 2019), and celebrities and content creators’ profiles who are the most followed pages on Instagram (Fardouly, Pinkus, & Vartanian, 2021). Hence, we hypothesize that: 3.3.1.2. Peer Influence Peers are powerful socialization agents who play an important role in reinforcing the value of appearance and interpreting media messages (Dohnt & Tiggemann, 2006; Lawler & Nixon, 2011; Jones & Crawford, 2006; Shroff & Thompson, 2006). Peer environment is characterized by a significant pressure to conform to appearance expectations, and deviations from these expectations lead to negative peer experiences (Kenny et al., 2017). In particular, interactions with peers might function as a means to verify the H1b: Social media influence has a positive effect on appearance comparison 66 self-objectification, body surveillance, or internalization, but as a multidimensional process that encompasses these three components. From this perspective, it is significant to stress the importance of internalization of beauty ideals in the process, since sexual objectification is triggered by exposure to female beauty ideals in media content (e.g., Aubrey, 2006a; 2006b). The original definitions of self-objectification and body surveillance do not include beauty standards. Selfobjectification primarily refers to a view of oneself as an object, and body surveillance primarily refers to the monitoring of one’s body (McKinley & Hyde, 1996; Noll & Fredrickson, 1998). However, in media research, which takes the sexualized focus on the ideal female body as a starting point (e.g., Aubrey, 2006a), self-objectification is described as the perception of oneself as a body composed of body attributes necessary for attaining the ideal body (Noll & Fredrickson, 1998), whereas body surveillance is interpreted as the act of observing and measuring oneself against a cultural ideal standard (Moradi, Dirks & Matteson, 2005; McKinley & Hyde, 1996). These conceptualizations implicitly or explicitly assume that an internalization of beauty standards has occurred and thus may precede selfobjectification and body surveillance (McKinley & Hyde, 1996; Noll & Fredrickson, 1998). In line with this suggestion, Morry and Statska (2001) reported that the relationship between media and self-objectification was mediated by the internalization of beauty ideals. Moreover, Harper and Tiggemann (2008) conceptualized objectification as an outcome that may result from internalization of the ultraslender ideal. Women who have internalized the thin ideal are compelled to engage in self-surveillance as a way to gauge their standing against that ideal; when a woman perceives herself as falling short of feminine beauty ideals, dissatisfaction with her body may result. This psychological internalization of an observer’s perspective toward one’s body lead to self-surveillance. Consistent with the multifaceted objectification framework, internalization stimulates the evaluation of oneself from an observer’s perspective, and, hence, internalization tend to trigger self-surveillance (Vandenbosch & Eggermont, 2012). Thus, we hypothesize: Objectification theory proposes that the negative consequences of self-objectification may result from women continually comparing their appearance to an unattainable cultural ideal and coming up short (Fredrickson & Roberts, 1997). Correlational studies have found an association between appearance comparisons and self-objectification (Lindner, Tantleff-Dunn & Jentsch, 2012; Tylka & Sabik, 2010), and those authors argue that this relationship may be bi-directional. This perspective is consistent with the H5: Internalization of appearance ideals has a positive effect on self-surveillance 67 circle of objectification proposed by Strelan and Hargreaves (2005), which suggests that women who self-objectify seek out appearance comparisons and these comparisons in turn lead to greater selfobjectification. Specifically, Strelan and Hargreaves argued that an increased focus on one’s appearance (i.e., high self-objectification) could lead to a greater tendency to make appearance comparisons and that, when making appearance comparisons to others, one’s own body and the body of the comparison target (e.g., a model in a magazine) are effectively reduced to objects, which may lead to an increase in self-objectification. A study by Lindberg and colleagues (2006), suggested that girls with high selfsurveillance more often compare their appearance with that of other girls. Another study by Fardouly et al. (2015), found that general appearance comparison tendency mediated the relationship between appearance focused media (magazine and social networking sites) and self-objectification. These authors indicated that comparing one’s appearance to others via the media, one may focus on the appearance of both oneself and the comparison targets. This process is likely to make one’s own appearance attributes more salient and possibly lead one to monitor and assess their physical appearance. Thus, we hypothesize: 3.3.3. Materialism This section will review consumer culture impact model, and the different conceptualizations of materialism. The relationship between internalization of appearance ideals and materialism will be discussed. Moreover, the impact of self-surveillance on materialism will be examined. As explained earlier, Dittmar (2007) conceived a consumer culture impact model to explain the connection between two prominent ideals propagated in the media in most contemporary societies. The body-perfect ideals, in which a particular body size and shape are emphasized and the material good life, which glorifies materialistic pursuits, such as money, possessions, and social status. Dittmar (2007) postulates that the two ideals are closely associated because both aim to satisfy an external definition of self. The cultural value attached to materialism and appearance makes people strive to achieve these ideals so as to gain status and social rewards (Dittmar, 2007; Kasser, 2002). In other words, if individuals manage to garner the material possessions, money, social status, and the good looks, they will be more likely to be satisfied with their lives. H6: Appearance comparison has a positive effect on self-surveillance 68 Materialism is largely the product of the modern capitalist society and the consumer culture that permeates it, which presents a pervasive value in contemporary society (Burroughs et al., 2013; Buckingham, 2011). Materialistic values represent a committed relationship with acquiring, possessing, and thinking about material things (Kasser 2002; Sheldon & Kasser 2008; Manolis & Roberts, 2012). Some individuals are vulnerable to the influence of materialism and believe that they should pursue these extrinsic goals in order to achieve success as defined by society (Dittmar, 2007). Individuals, consciously or unconsciously, have learned to evaluate their own well-being and accomplishment not by looking inward at spirit or integrity, but by looking outward at what they have and what they can buy. Similarly, people have adopted a world view in which the worth and success of others is judged in terms of what is possessed, the right clothes, the right car, and more generally, the right stuff. Furthermore, a significant number of studies have investigated materialism according to differences between women and men and have confirmed that women are more materialistic compared to men (Barzoki, Tavakol & Vahidnia, 2014). Materialism has been conceptualized in different ways in the literature. Within the field of psychology, there are three major approaches that have attempted to define and measure materialism (Barzoki, Tavakol & Vahidnia, 2014, p. 154). First is Belk materialism scale (1984) which conceptualized materialism as a multifaceted personality trait and defines it as “the importance a consumer attaches to worldly possessions” (p. 291). The second approach by Richins and Dawson (1992, p. 308) theorize materialism as a personal value and define it as a “set of centrally held beliefs about the importance of possessions in one’s life.” Richins and Dawson developed the material values scale and conceptualized materialism in terms of three domains referred to as centrality, success, and happiness (Richins, 2004). Centrality is the belief that material possessions and acquisitions are highly important in life. Success refers to the extent to which people see possessions and money as a viable yardstick for evaluating their own achievements, as well as those of others. Finally, happiness holds that goods and money are the main paths to personal happiness, a better life, and a more positive identity. According to this approach, materialism is a socially constructed phenomenon, in the sense that its meanings are communicated within consumer culture and are shared among a large number of individuals. In this way, materialistic values represent a committed relationship with material goods expressed by both individuals and the society. The advantages of this theoretical approach are that it fully considers the influence of consumer culture and the shared meanings of materialism, and that it captures differences in the extent to which individuals endorse materialistic values. The third approach is the relative importance of financial goals. This approach involves the relative financial goal perspective 69 as well as materialistic beliefs about the status and a positive identity through material goods (Kasser 2002; Kasser & Kanner, 2004). In line with, Richins and Dawson (1992) conceptualization of materialism as a socially constructed phenomena, and Dittmar consumer culture impact model (2007), we suggest that materialism and appearance may best be understood not as separate constructs but as two integral parts of an overarching consumer culture value orientation. The internalization of body-perfect ideal showed a strong and positive association with the internalization of materialistic values providing support that the body perfect and the material good life ideals are frequently portrayed together in advertising. Media and advertising manage to create a seamless association between people with right appearance and the right material possessions (Guðnadóttir & Garðarsdóttir, 2014). This falls in line with previous theoretical (Dittmar, 2007), experimental (Ashikali & Dittmar, 2012), survey (Easterbook, Wright, Dittmar & Banerjee, 2014), and qualitative (Wright et al., 2011) research, which have all found both constructs to be strongly related to each other. Ashikali and Dittmar (2012) suggested that materialistic messages make appearance-related thoughts salient. In other words, materialism heightens the centrality of appearance in women, whereby they are likely to relate to their bodies as they might relate to other objects. Moreover, Henderson-king and Brooks (2009) posited a significant relationship between internalisation of appearance ideals and materialism. Likewise, Guðnadóttir and Garðarsdóttir (2014) demonstrated that materialism is positively correlated with the internalization of body perfection ideals for women. Thus, we develop further hypothesis that: Body objectification theory states a separation of the body from the person (Bartky, 1990) and consequently positions the body as a possession of the extended self rather than an integral part of the core self, the same as the incorporation of material possessions into the self (Belk, 1988). Objectifying environments and materialistic beliefs have stimulated people to value physical appearance (Li & Xiao, 2021) The mechanism underlying materialism and self-objectification is dependent on self-valuation, materialists measure their self-worth in terms of material possessions and money they own; women who self-objectify evaluate their worth based upon physical appearance and sexuality. In a modern consumerist society, these two sets of values are interconnected and perpetuated together by advertisements emphasizing women's bodies. Reviewing the literature, we have found that there is a H7: Internalization of appearance ideals has a positive effect on materialism 70 bidirectional relationship between materialism and self-objectification. However, the majority of prior research has examined the effect of materialism on self-objectification (Teng et al., 2016a; 2016b; 2017; Sun, 2018a; 2018b). Teng et al. (2016a) by means of an experimental study provided support that priming materialistic belief would increase women’s self-objectification. In line with this research, Teng et al. (2016b) in their study with a Chinese sample showed that the more materialistic women are, the more likely they are to take an objectifying perspective toward themselves. Similarly, Teng and colleagues (2017) posited that materialism increased female’s self-objectification tendency, and body surveillance mediated the effect of materialism on women’s appearance management intentions. Moreover, Henderson-King and Brooks (2009) revealed that people who subscribe to the materialistic values in the consumer culture tend to self-objectify more. Additionally, Sun (2018a) posited in their study that higher materialism predicted higher body surveillance and body shame. Few studies have also examined the effect of sexual objectification on materialism. A study by Haddadi Barzoki and colleagues (2014) investigated this relationship among an Iranian sample. The authors provided evidence for the negative effects of objectification and body surveillance on consumption and materialism. That is due to current standards, body surveillance plays a significant role in one’s tendency toward conspicuous consumption and materialism. The dominant sexual atmosphere of the society and the media lead to a certain perception among women of their bodies, and this factor, directly or indirectly, results in their tendency to consume more. Self-objectified perception requires consumption and hence money, and over time this need turns into a way of thinking. In this study, we examine the influence of materialism on self-surveillance in women. Thus, we hypothesize: 3.3.4. Attitudes towards Cosmetic Surgery In this section we will discuss three direct predictors for cosmetic surgery attitudes, namely, selfsurveillance, materialism, and religion. In accordance with objectification theory, facets of objectified body consciousness (e.g., self-surveillance) have robust links with disturbances in body image and appearance-modifying attitudes and behaviours (Li & Xiao, 2021; Jackson, Zheng & Chen, 2015; Calogero et al., 2010). Positive attitudes toward cosmetic surgery among women reflect another negative consequence stemming from the sociocultural H8: Materialism has a positive effect on self-surveillance 71 conditions that perpetuate the objectification of women’s bodies. Indeed, the remarkable increase in elective cosmetic procedures (surgical and minimally invasive) over the past decade is due primarily to the disproportionately higher number of female patients who sought these procedures. A study by Calogero and colleagues (2010) examined the relationship between objectification theory variables and cosmetic surgery attitudes among a sample of women living in the U.K., a cultural context within which women consistently report high levels of appearance concerns, sexual and self-objectification, and interest in cosmetic surgery (Calogero, 2009). The authors argued that self-surveillance was a unique predictor of intrapersonal reasons for cosmetic surgery; women who engage in more habitual body monitoring are more self-focused, and therefore would be more likely to endorse strategies that could potentially improve how they view their appearance (Calogero et al., 2010). Another study by Calogero and colleagues (2014) revealed that priming self-objectification increased intentions to have cosmetic surgery. Consumption of cosmetic surgery was underscored as a harmful micro-level consequence of self-objectification that may be perpetuated via subtle exposure to sexually objectifying words, even in the absence of visual depictions or more explicit encounters of sexual objectification (Calogero, Pina, & Sutton, 2014). Furthermore, Ching and Xu (2019) indicated that features of objectified body consciousness particularly body surveillance was closely associated with cosmetic surgery attitudes in a Chinese sample. Similarly, Jackson and Chen (2015) postulated remarkable increases in cosmetic surgery rates of young Chinese women traced to macro-level processes including body surveillance. Researchers based in the U.S. (e.g., Fredrickson & Roberts, 1997; McKinley & Hyde, 1996) and Australia (Tiggemann, 2013) have noted that body surveillance, appearance anxiety, and body shame may predict increasingly favourable attitudes toward appearance modification efforts (e.g., cosmetic surgery) that more closely align one’s appearance with prescribed appearance ideals. As such, pervasive sexual objectification of women as a macro-level context produces a chain of negative micro-level consequences known to occur at a disproportionately higher rate among women. Hence, drawing from and extending objectification theory (Fredrickson & Roberts, 1997), we investigate the possibility that women’s experiences of self-surveillance would predict more positive attitudes toward cosmetic surgery as a way of manipulating how their bodies look. Thus, we hypothesize: H9: Self-surveillance has a positive effect on attitude towards cosmetic surgery 72 The prevailing materialism in a consumerist society heightens the centrality of appearance in women, luring them into buying products and services that would bring them closer to culturally prescribed ideals (Teng et al., 2016b). Materialist individuals are likely to relate to their bodies as they might relate to other objects. Thus, the allure of new products and techniques for modifying one’s appearance may be more appealing to those who have a materialist, rather than nonmaterialist, orientation. Henderson-King and Brooks (2009) found that women with strong materialist values have more positive attitudes toward cosmetic surgery. Indeed, Featherstone (1999) claims that individuals who perform body modifications may feel a sense of control over their body and that they “somehow have taken possession of their body” (p. 2). An emerging body of research demonstrates that materialistic values contribute to body image concerns and willingness to consider cosmetic surgery (Ching & Xu, 2019; Sun, 2018b; Guðnadóttir & Garðarsdóttir, 2014; Felix & Garza, 2012; Dittmar, 2007). Experimental evidence provided insights into how materialism affects people’s appearance concerns. In a study conducted in the United Kingdom, Ashikali and Dittmar (2011) showed that priming materialism increased appearance-based self-concept and activated body-related discrepancies, particularly for women who were already highly materialistic. In another study conducted in China, Teng et al. (2017) indicated that materialism increased women’s appearance-contingent self-worth and their tendency to consider sexual attractiveness as capital for accruing personal benefits. This falls in line with Sun (2018b) study which found that materialism influence young Chinese women’s cosmetic surgery consideration, as those who endorse materialistic values may use cosmetic surgery to reduce the gap between their own appearance and ideal beauty. Likewise, Ching and Xu (2019) have revealed that materialism is among the factors that predict greater willingness to consider cosmetic surgery. For this reason, we hypothesize: Religiosity and the practice of religion constitute a vital part of the lives of many people around the world (Mathur, 2012). It is not only viewed as the core of a culture’s belief system, but religiosity is also known to influence people’s behaviour in all aspects of life especially physical health and well-being (Ypinazar & Margolis, 2006). Although religious scholars have attempted to develop a unified agreement about the conceptualisation of religiosity, many believe this task may not be possible (Atran & Norenzayan, 2004; Hood, Hill, & Spilka, 2009). The variances in the characterisation of religiosity and the ambiguity in H10: Materialism has a positive effect on attitude towards cosmetic surgery 73 definition is due to the existence of different faiths and belief systems around the world. Each spiritual group defines religiosity from their point of view, both conceptually and operationally (one-dimensional vs. multi-dimensional) (Mathur, 2012). Moreover, when academics approach the concept of religiosity within research, each would address religiosity from a different perspective, making the concept harder to define (Cardwell, 1980). Religion is commonly defined as an integrated system of shared beliefs, practices, and commonly held sacred symbols (Atran & Norenzeyan, 2004; Delener, 1990) which form broader shared cultural ideologies (Saroglou, 2011). Personal religiosity provides a background against which the ethical nature of behaviour is construed (Ramly, Chai & Lung, 2008). Glock and Stark (1965) defined religiosity as a value-based approach that provides a person with a system of norms and values. They identified five dimensions of religiosity: experiential (religious feelings), intellectual (knowledge about religion), ideological (beliefs), ritual (religious behaviour), and result-oriented (influences of religion) (Fisherman, 2011). Greenfield and Marks (2007) incorporated the community dimension of religion, whereby religion often helps satisfy individuals need for group identification and affiliation. Most scholars agree that religion is a multidimensional construct (Arli, 2017). As such, Schmidt et al.’s (1999) defines religion as “systems of meaning embodied in a pattern of life, a community of faith, and a worldview that articulate a view of the sacred and of what ultimately matters” (p. 10). Similarly, Saroglou (2011) identifies four dimensions of religion: beliefs, rituals, values, and community. Religious values (religiosity) are broadly viewed as the commitment one has to belief in the divine and the importance one places on religion in life (Putney & Middleton 1961). For individuals with strong religious values, religion represents one of the most important aspects of their lives and influences their attitudes and behaviours (Weaver & Agle, 2002). The dogma of most religions including Islam, Christianity, and Judaism deeply affects human behaviour and attitudes. Hence, studies on the effect of religion on consumer psychology and behaviour is prominent. The study of religion in consumer research has been largely situated within the arena of consumer culture, whereby researchers have investigated the religious-like aspects of consumer culture (e.g., Belk & Tumbat, 2005). Moreover, the impact of religious beliefs on perceptions of physical health and illness has been examined in many studies (Damiano et al., 2019; Lucchetti & Lucchetti 2014). When examining cosmetic surgery, previous research has shown that religiosity is a powerful determinant of attitudes towards and acceptance of cosmetic surgery (Muslu & Demir, 2020; Furnham & Levitas, 2012; Atiyeh et al., 2008). According to Islam and the Holy Quran which is the primary source of all life’s teachings and rules to Muslims, “God created man in the most perfect form’’ (95:4). Each human life has its own inherent 74 value and goodness but may theoretically render any further improvement in one’s appearance rather unconceivable. However, in cases of absolute necessity wherein religiously lawful alternatives do not exist, Islamic teachings, allow even for sacred law to be suspended, temporarily: ‘‘But if one is compelled by necessity, neither craving nor transgressing, there is on him no sin, for indeed Allah is Clement, Merciful’’ (2:173) (Gatrad & Sheikh, 2001). In other words, essential surgery genuinely needed to correct unusual physical defect is permissible because it is not meant to change the creation of God. However, surgery performed for beautification is unnecessary and is therefore unlawful (‘haram’) and not permissible (Atiyeh et al., 2008). The body given to us is a trust and changing the nature created by Allah is a sin. Hence, mutilation of one’s body through cosmetic surgery is clearly prohibited in Islam. Other religious scholars of different faiths view cosmetic surgery as a direct contravention to their religious beliefs. Christian scholars strongly advocate the view that people should be less concerned with physical appearance (Philippians 2:3-4) and more concerned with religious issues (Proverbs 31:30) and that true beauty lies within an individual’s spirit (1 Peter 3:4). In Judaism, human body is divine property over which humans cannot assume a possessive right, and self-mutilation or any form of assault upon the body is viewed as a breach of this stewardship (Rosner, 2000). Hence, it is suggested that religiously conservative individuals of all faiths will have stricter views about sins of vanity and will be less likely to undergo cosmetic surgery than more liberal or atheist individuals (Furnham & Levitas, 2012). In Egypt, Islam is the national religion. Almost 90% of Egyptians are Muslim and around 10% are of Christian faith (CAPMAS, 2016). Islam is interpreted as a critique of modernization and Western values and ideals including capitalism and consumerism (Izberk-Bilgin, 2012). As mentioned earlier, Islam has religious principles that forbid and discourage the consumption of cosmetic surgery for cosmetic purposes, and it is considered ‘haram’ and impermissible. According to the study of Muslu and Demir (2019), there was a significant relationship between worship practices which are the important indicators of belief levels in Islamic religion, and aesthetic surgery attitudes. Hence, this research is concerned with how the importance of religion in women’s life affects their attitudes towards cosmetic surgery. Thus, the following hypothesis is stated: H11: Religion has a negative effect on attitude toward cosmetic surgery 75 3.3.5. Factors Associated with Cosmetic Surgery Prediction In recent years, body image research has attracted attention. The term ‘body image’ incorporates themes of body perception (the extent to which an individual has an accurate perception of their body size, shape, and weight) and body satisfaction (the extent to which an individual is satisfied with their body size, shape, and weight). It is a multidimensional concept that is defined as “a person’s perceptions, thoughts, and feelings about his or her body” (Grogan, 2006). According to the Tripartite Influence Model, sociocultural (e.g., media, peers, and family) and psychological factors (e.g., internalisation of appearance ideals, appearance comparison) interact and directly influence body image (Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999). Any disturbances in the perceptions and attitudes toward the body is termed body image concerns, which entails a negatively distorted view of one’s appearance (i.e., body dissatisfaction). Body-dissatisfaction defined as “person’s negative thoughts and feelings about his or her body” (Grogan, 2008, p. 4) has been a common problem among young women. A significant body of research has focused on body dissatisfaction especially thin ideals, and its relationship to cosmetic surgery intentions or acceptance among women (Biolcati et al., 2017; Sharp et al., 2014; Markey & Markey, 2009). However, there are other body image concerns that research has recently started to examine, such as facial appearance dissatisfaction; feeling unhappy about one’s own facial appearance (e.g., Ching & Xu, 2019; Jackson & Chen, 2015). According to Jackson and Chen (2015), overall body dissatisfaction was not related to cosmetic surgery consideration levels of young Chinese women in contrast with past work linking body dissatisfaction to cosmetic surgery interest. Instead, a specific, culturally salient source of appearance dissatisfaction reflecting facial appearance emerged as the strongest individual predictor of cosmetic surgery attitudes among women. Similarly, Ching and Xu (2019) posited that facial appearance concerns explained a significant amount of variance in cosmetic surgery consideration. Hence, in some cultures, facial dissatisfaction had a greater impact on the willingness to consider cosmetic surgery than body dissatisfaction. A large body of research has documented the influence of appearance concerns on attitudes towards cosmetic surgery (Menzel et al., 2011; Slevec &Tiggemann, 2010; Markey & Markey 2009). However, previous research was correlational, suggesting an increased likelihood that body or facial dissatisfaction is influencing desire for cosmetic surgery but not a causational influence. Therefore, this research aims to examine how attitudes towards cosmetic surgery prompt women to pay greater attention to the attractiveness of their faces and in turn increase their facial appearance concerns. Thus, we hypothesize: 82 assumptions have direct implications on a third set of assumptions which is the methodological nature, which lead to the question of how the researcher can investigate and obtain knowledge about the social world. Methodology is a theoretical and philosophical system that structures the way research is conducted (Guba, 1990). According to the theory of science, relationships among these constructs are as such: ‘ontology defines epistemology, which in turn defines methodology, which then determines applied methods’ (Slevitch, 2011, p.75). In business and management research, philosophies are scattered along a multidimensional set of ranges (Niglas, 2010) between two opposing paradigms: objectivism and subjectivism. According to Saunders et al. (2007), objectivism incorporates the assumptions of the natural sciences, arguing that the social reality that we research is external to social actors. From an objectivist viewpoint, social and physical phenomena exist independently of individuals’ views of them. Hence, the interpretations and experiences of social actors do not influence the existence of the social world. This means that, ontologically, objectivism embraces realism, which, in its most extreme form, considers social entities to be like physical entities of the natural world, as they exist independently of how we think of them, label them, or even of our awareness of them. Realism postulates that the individual is seen as being born into and living within a social world which has a reality of its own. It is not something which the individual creates, it exists out there: ontologically it is prior to the existence and consciousness of any single human being (Burrell & Morgan, 2017). From an objectivist/realist viewpoint, the social world has an existence which is as hard and concrete as the natural world. Epistemologically, objectivists seek to discover the truth about the social world, through universal facts, from which law-like generalisations can be drawn about the universal social reality. On the other hand, subjectivism incorporates assumptions of the arts and humanities, asserting that social reality is made from the perceptions, opinions, and consequent actions of social actors (people). Ontologically, subjectivism embraces nominalism. Nominalism, in its most extreme form considers that the order and structures of social phenomena we study are created by social actors through use of language, concepts, labels and consequent actions. For nominalists, there is no underlying reality and a real structure to the social world beyond what people (social actors) attribute to it, and, because each person structures and experiences reality differently, nominalists assume there are multiple realities rather than a single reality (Burrell & Morgan, 2017). In this thesis, the objectivism/realism philosophy is the standpoint that guides the research, which holds that the social world exists independent of human perceptions (Sale et al., 2002). The overarching research question in this thesis: “what is the impact of sociocultural influences, psychological influences, 83 individual level materialism and religiosity in the attitudes towards cosmetic surgery; and the impact of facial appearance concerns on the relationship between attitudes and intentions to undergo cosmetic surgery? In this regard , the researcher follows the physical world and assumes that the social world is made up of major social structures such as family, peers, religion, and health care providers into which humans are born. The researcher reflects reality and examines an emerging phenomenon in contemporary society which is the consumption of cosmetic procedures. The researcher also accepts the existence of a world of cause and effect as the aim of this research is to understand the theoretical underpinning for women’s attitudes and behavioural intentions towards their bodies. Hence, the researcher is in investigating the impact of sociocultural influences presented by the social media, peers, and family on how individuals view themselves and the implications this has for their attitudes and behavioural intentions towards their bodies. There are many research philosophies that serve as a guide for various studies that are carried out. These philosophies are different in many aspects. However, in business and management research, there are five major philosophies: positivism, critical realism, interpretivism, postmodernism and pragmatism (Saunders et al., 2007). Positivism relates to the philosophical stance of the natural scientist and entails working with an observable social reality to produce law-like generalisations. Ontologically, positivists believe that there is one real and independent true reality in order to understand the world well enough and consequently interpret, forecast, and control it (Sekaran & Bougie, 2016). Hence, positivists advocate the application of the methods of the natural sciences to the study of social sciences (Bryman, 2016). Epistemologically, positivists focus on discovering observable and measurable facts, the only phenomena that you can observe, and measure would lead to the production of meaningful data. Hence, science and scientific research can be specified as a cornerstone of positivism philosophy, and the only method to develop knowledge or data uninfluenced by human interpretations or bias. For a positivist researcher, the world operates by laws of cause and effect that we can perceive if we use a scientific approach to research. Hence, positivists usually use a deductive reasoning method to put forward existing theories that they can test by means of a fixed, predetermined research design and objective measures. The purpose of theory is to generate hypotheses that can be tested to be proved or disproved leading to further development of theory which then maybe tested by further research. Consequently, the aim of scientific investigation would be to measure and analyse causal relationships among phenomena within a value-free framework; where the researcher remains neutral and detached from research to avoid influencing the results. Positivists are concerned with the rigor and replicability of 84 their research, the reliability of observations, and the generalizability of results (Sekaran & Bougie, 2016). The key approach of positivist researchers is observation and experimentation which authorises them to test cause‐and‐effect relationships to create law-like generalisations. Critical realism is a philosophy that sits between positivism and interpretivism. It is a belief in an external objective reality that operates independent of our awareness, but not directly accessible through our observation and knowledge of it (Saunders et al., 2007). Critical realists distinguish between the “real world” and the “observable world” (Alderson, 2021). The real world cannot be observed and exists independent from human perceptions, theories, and construction. The world as we know and understand it is constructed from our perspectives and experiences through what is “observable”. Thus, according to critical realists, unobservable structures cause observable events, and the social world can be understood only if people understand the structures that generate events. Although critical realists agree with positivists that reality is external to us, they argue that we cannot rely on positivist reasoning to understand the world, hence addresses the traditional concerns of social science (e.g., causation, agency, structure & relations) (Archer et al., 2016). Any of these concerns need to be justified and should not be taken for granted. Critical realists believe that our knowledge of the world is historically, socially, and culturally situated. Thus, critical realism shares the same view with interpretivism that social phenomena are concept dependent and need interpretive understanding. The opposite research philosophy to positivism is Interpretivism. Interpretivist research philosophy emphasizes that social sciences differ in essence from that of natural sciences, and that humans and their social worlds cannot be studied in the same way as physical phenomena (Sekaran & Bougie, 2016). Scientists and researchers who adopt an interpretivism epistemological position, highlight the distinctiveness of humans as against the natural order because they generate meanings and knowledge. Different people from different cultures and languages, under different environments and at different times make different meanings, and so create and experience different social realities. Therefore, the study of the social world therefore requires a different logic of research procedures. Interpretivists are critical of the positivist application of scientific model to the study of the social world, and their attempts to discover definite, universal laws that apply to everybody. Rather they believe that the uniqueness of humans, and their rich insights and interpretations of the social world are lost if such complexity is reduced entirely to a series of law-like generalisations (Saunders et al., 2007). With its focus on complexity, richness, multiple interpretations, and experiences, interpretivism is explicitly subjectivist. The research methods of interpretivist researchers are often qualitative in nature. They collect rich data through focus groups and unstructured interviews, seeking the contextual 85 uniqueness of the world that is being studied. Certainly, interpretivists focus on understanding a specific case rather than results generalisation (Saunders et al., 2007). Therefore, it is believed in this philosophy that the world is basically mentally constructed. Thus, interpretivists aim to comprehend the rules people use to make sense of the world by alternative approaches to research instead of pursuing the objective certainty. Postmodernism is another philosophical stance that is characterized with the prominent role of language, power relations, and scepticism towards the accepted ways of thinking and giving voice to alternative disempowered views. Postmodernists go even further than interpretivists in their critique of positivism and objectivism, attributing even more importance to the role of language. They deny that there are aspects of reality that are objective, or that there are statements about reality that are objectively true or false and disagree that it is possible for human beings to know about things with certainty. Instead, reality, knowledge and values are constructed collectively. However, these collective choices in turn, are shaped by the power relations and by the ideologies that dominate contexts (Faith, 1994). Hence, postmodernism reflects the unjust hegemony by the powerful people, and stresses that other supressed perspectives are potentially just as valuable and have the power to create alternative worlds and truths. Hence, postmodernism emphasizes movement and change, through the voicing of subjective and multiple opinions of individuals rather than the predetermined rules for action. The last philosophical stance is Pragmatism, which is a philosophy that strives to reconcile both objectivism and subjectivism. Pragmatists do not take on a particular stance on what constitutes good research. They feel that research on both objective, observable occurrences and subjective meanings can produce useful knowledge. However, the most important determinant for research design and strategy would be the research problem and the research question. Pragmatists emphasize the relationship between theory and practice. For a pragmatist, theory is derived from practice, and the value of research lies in its practical importance (Sekaran & Bougie, 2016). Pragmatism describes research as a process where concepts and theories are generalizations of our previous actions, experiences, and interactions with our surroundings. Pragmatists hence stress the socially constructed nature of research, different researchers may have different viewpoints about, and justifications for, what is happening around us. For the pragmatist, these different perspectives, ideas, and theories help us to gain an understanding of the world; pragmatism thus endorses pluralism. In this thesis, the positivism philosophy is the standpoint that guides the research, where the foundations of social psychology theories are applied to study the consumer behaviour as the main approach to this research. From these theories, such as social comparison theory, and objectification 86 theory, hypotheses are developed and empirically tested. Thus, this thesis considers that the objective truth is represented in the theories used to develop the research hypotheses. As such, the study has clear constructs which are developed as per reviewing the literature. These constructs were represented in sociocultural influences (social media, peer, and family), internalization of appearance ideals, appearance comparison, self-surveillance, materialism, attitudes towards CP, facial appearance concerns and behavioural intentions. Such constructs were identified through theories investigated in previous studies related to consumer behaviour. The positivism philosophy is used here as it is believed that reliability of observations and generalisability of results are vital through testing the constructs developed from literature using a representative sample and a pre-developed scale. A model is to be developed and investigated by means of a planned research design and unbiased measures by using deductive reasoning of having general theories as mentioned and such theories are examined in the context of CS. 4.3. Research Approach A researcher’s choice of the research approach stems from the philosophical stance that guides the entire research (Burns, Bush & Sinha, 2014). According to the research approach, the data collection method and procedures are determined within the research plan and framework. Such selection helps in specifying the required analysis, which in turn figures out a relevant response for the main research question (Burns, Bush & Sinha, 2014). In the same way, Cooper and Schindler (2014) claimed that specifying the research approach is considered as a supporting stage for the researcher to specify the research conceptual model as well as the research method for sampling and sample size, research variables operationalization and measurement, techniques used for data analysis, which links the research plan with the research question (Creswell & Clark, 2017). There are several classifications of research approach: exploratory, descriptive, and causal. First, exploratory research is assigned to gain insights about a certain topic, explore an issue, problem, or phenomenon. Exploratory research is developed when existing research results are unclear or there is not enough theory available to guide the development of a theoretical framework (Sekaran & Bougie, 2016). A researcher conducting exploratory research may commence with a broad focus, and a research problem that is not well-structured, but this will become narrower as the research progresses. Hence, exploratory research often relies on qualitative approaches to data gathering such as interviews, focus 87 groups, and/or case studies. Exploratory research is flexible in nature and adaptable to change, the researcher must be willing to change their direction as the research progresses. Second, descriptive research is used in studies that aim to obtain data that describes the topic of interest and provide an orderly description of a problem that is well structured and clear (Cooper & Schindler, 2014). Descriptive studies are often designed to collect data that describe characteristics of objects (e.g., persons, organizations, products, or brands), events or situations (Sekaran & Bougie, 2016). Descriptive research is either quantitative or qualitative in nature. It helps the researcher provide a systematic description that is real and as accurate as possible; especially when the topic being investigated is clear, without the goal to understand cause and effect associations (Cooper & Schindler, 2014). Correlational studies describe relationships between variables. While correlational studies can suggest that there is a relationship between two variables, finding a correlation does not mean that one variable causes a change in another variable. Third, causal studies test whether one variable causes another variable to change. In a causal study, the researcher is interested in delineating one or more factors that are causing a problem (Sekaran & Bougie, 2016). Causal studies are at the heart of the scientific approach. For a positivist, the world operates by laws of cause and effect that can be discerned if a scientific method to research is used. According to Hair et al. (2014), the strongest type of theoretical inference a researcher can draw is a causal inference. Although SEM is often referred to as causal modelling, causal inferences are only possible when evidence is consistent with four conditions for causality: covariation, sequence, nonspurious covariation, and theoretical support. SEM can provide evidence of systematic covariation and can help in demonstrating that a relationship is not spurious. If the research design involves experiment or longitudinal data, SEM can also help establish the sequence of relationships. However, in cross-sectional surveys, measuring all of the variables at the same point in time does not provide a way of accounting for the time sequence. Thus, theory must be used to argue that the sequence of effects is from one construct to another. In this study, the researcher aims to investigate the impact of sociocultural influences, psychological influences, individual level materialism, and religiosity in attitudes towards CS. In addition, the impact of facial appearance concerns on the relationship between attitudes and intentions to undergo cosmetic surgery. As such, this study aims to draw causal inferences among the mentioned constructs, by specifying the structural model and assigning relationships from one construct to another based on a theoretical model. Thus, the researcher finds that a causal approach is best used to address the research problem. 88 Regarding the methodological approach, the research approaches are commonly divided into three main forms: deductive, inductive, and abductive. The deductive approach is undertaken when the researcher starts with theory, often developed from the academic literature, and then design a research strategy to empirically test the proposed hypothesis or theory. Conversely, the inductive approach is undertaken when the researcher starts by collecting data to explore a phenomenon and generate or build theory (often in the form of a conceptual framework). The deductive approach takes more of a “testing theory” method, where the inductive approach takes a “building theory” viewpoint. Instead of moving from theory to data (as in deduction) or data to theory (as in induction), an abductive approach moves back and forth, in effect combining deduction and induction (Suddaby, 2006) . In an abductive approach, data is collected to explore a phenomenon, identify themes, and explain patterns, to generate a new or modify an existing theory which you subsequently test through additional data collection. In this research, the researcher finds that a deductive approach is best used to address the research problem, as the research is investigating a consumer behaviour that is associated with the consumption of cosmetic procedures using existing theories such as sociocultural, self-objectification, social comparison theories and others that are used to deduce, describe, and test hypotheses related to the formation of women’s attitudes and behavioural intentions towards CS. This approach will aid this research in gaining additional knowledge of the nature of the research problem, guide the research strategy by which the data will be collected and tested. 4.4. Research Strategy A research strategy is defined as a plan of how a researcher will go about answering the research question/s. It is the methodological link between the philosophy and subsequent choice of methods to collect and analyse the data (Denzin & Lincoln, 2018). Hence, the philosophical position and research approach guide the researcher when selecting the way, they will investigate the research problem and study. There are three main research strategies that can be approached: qualitative research, quantitative research, and mixed methods. Qualitative research explores and comprehend the meanings individuals and groups assign to a social or human problem (Creswell & Clark, 2017) . However, the quantitative approach examines relationships between variables, which are measured numerically and analysed using a range of statistical and graphical techniques (Creswell, 2014; Sekaran & Bougie, 2016). A mixed methods approach integrates both quantitative and qualitative data collection techniques and analytical procedures (Molina-Azorin et al., 2017). 89 Quantitative research designs are generally associated with positivism philosophy, especially when used with predetermined and highly structured data collection techniques, it is also usually associated with a deductive approach, where data are collected and analysed to test theory (Saunders et al., 2007). However, it may also incorporate an inductive approach, where data are used to develop theory. On the other hand, qualitative research is often associated with an interpretive philosophy (Denzin & Lincoln, 2018), as researchers need to make sense of the subjective and socially constructed meanings expressed about the phenomenon being studied. Qualitative research often commences with an inductive approach to build theory or to develop a richer theoretical perspective. Mixed methods approach is based on philosophical assumptions that mix quantitative and qualitative collection techniques and analysis procedures (Molina-Azorin et al., 2017). Hence, two philosophical positions are often associated with mixed methods designs: pragmatism and critical realism. Correspondingly, mixed methods research design may use a deductive, inductive, or abductive research approach. Since this study uses a deductive approach, a quantitative method is followed. Hence, the focus is on collecting, testing, and deducing numerical data in a planned, organized manner by using statistical techniques and a representative sample of the population. The study uses this approach to provide deductive reasoning to create meaning, establish, confirm, and validate the relationships between variables. In this study, a research problem is first identified, various theories were used to formulate hypotheses then the quantitative data was analysed to confirm the findings. This strategy has been followed as there are well-structured theories and reliable constructs represented in social media influence, peer influence, family influence, internalization of appearance ideals, appearance comparison, self-surveillance, materialism, religiosity, attitudes towards CS, facial appearance concerns and behavioural intentions. According to the classifications stated above of research philosophy, research approach and strategy, it could be argued that this research is following the positivism philosophy, as it applies the theories discussed by the researcher in literature to examine women’s attitudes and behavioural intentions towards CS in Egypt. Therefore, constructs had been defined, where a causal approach is used to test relationships among the research constructs through a quantitative design implemented using pretested scales. Subsequently, the study used deductive reasoning to explain the theories and the research constructs obtained in the previous step. A quantitative design is applied using an online questionnaire administered from pretested scales of the assigned variables. The following section explains in detail the data collection process and how the questionnaire was adapted after handling preliminary steps of pretest and pilot study to validate the research variables. 90 4.5. Data Collection and Sampling Procedure For the data collection, a questionnaire was developed using and adapting pre-existing measures (Section 4.5.2.3, presents the development of the constructs in detail). As a preliminary step to begin the quantitative approach, the questionnaire was pre-tested by three academics to ensure for clarity, comprehension, and consistency. To confirm the development of the questionnaire, a pilot study was conducted as well with the aim of testing the items that measure the constructs/research variables in the Egyptian context. A link to the questionnaire was sent to 30 respondents, to refine the questionnaire and check its presentation. The pilot study allowed the gathering of information prior to a larger study, to improve the quality and proficiency of the quantitative instrument. It also allowed detecting any problems in the questionnaires before distributing them on a larger scale (Bryman, 2016). Although cosmetic surgery has become prevalent in the Middle Eastern culture, most of the empirical work and various studies undertaken take place in Western cultures with little focus on Egypt. Moreover, the theories and scales used to measure the variables in this study were developed in Western countries and can include certain statements or words that might not be applicable in Egypt or might have another meaning to Egyptian respondents. As such, a pilot study can help tackle these concerns. Hence, after conducting the pilot study, internet questionnaires were used as a main data collection method. Figure 9 shows the research strategy. Figure 9 - Data Collection Procedure Questionnaire Development Pre-test: -Ensure for questionnaire clarity, comprehension, and consistency -Suggestions to be made on the structure of the questionnaire Pilot study: Pretesting the items that measure the constructs of the study in the Egyptian context Data Collection: Administering of internet questionnaires as main data collection method 91 The following section explains in detail the data collection process and how the questionnaire was adapted after handling preliminary steps of pre-test and pilot study to validate the research variables. There are different data collection methods that are determined based on the research approach and strategy that are specified in the previous sections. Data collection methods are like experiments, surveys, interviews, observations, grounded theory, case studies and mixed methods (Sekaran & Bougie, 2016). Indeed, a great deal of social science research relies on questionnaires (Hair et al., 2014). This research used self-administered online questionnaires, which refers to a questionnaire that has been designed specifically to be completed by a respondent without intervention of the researcher to collect the needed data. The self-administered online questionnaire was created and sent out to respondents through a webbased survey tool (Qualtrics software). It contained a set of systematically organised and structured questions in which response-options were predetermined to get the desired information from respondents. Questionnaires were suitable to use when researchers know exactly what is required. Hence, they always have a definite purpose that is related to the objectives of the specified research (Bryman, 2016; Sekaran & Bougie, 2016). Self-administered online questionnaires have some advantages to this study, the data collection method was easy, fast, and economical. Moreover, the online questionnaires were useful in describing the features and traits of the large population and made large samples feasible; it allowed the researcher to gain access to groups and individuals through the Internet and social networks, which would have been difficult to reach through other channels. The questionnaires accommodated the researcher in gaining wider data to test the existing hypotheses. As such, a link of the questionnaire was sent to the respondents via social media platforms (e.g., Instagram, Facebook, and WhatsApp) to complete at their convenience and at their own pace. Before the process of data collection, the study should be precise regarding the target population and the sample used for the purpose of research. The following section introduces the population and sample (Section 4.5.1), and the second section presents the questionnaire design (Section 4.5.2). 4.5.1. Population and Sample The population is defined as the total number of all objects, subjects or individuals of interest that conform to a set of specifications and characteristics, and through which data can be collected and analysed. Typically, collecting, and analysing data about the entire population is impracticable owing to restrictions of time, cost, and access (Saunders & Townsend, 2016). Thus, a target population should be defined, which is often a subset of a population, and is the actual focus or target of the research inquiry. The 98 where the questions were related to sociocultural influences (social media, peer, and family), religiosity, and materialism constructs. The third section was regarding facial appearance concerns construct, and the fourth section was about respondents’ attitudes towards cosmetic procedures, where the researcher defined and provided examples on surgical and non-surgical procedures. Finally, the last section inquired about respondents’ intentions to undergo CS. All the assessed variables in this section used a Likert type scale. The scales used to measure each construct under study were chosen through a rigorous selection process. To operationalize the constructs, the first step was to conceptually define them in light of the study. For example, in this study, the construct “Peer influence” represented “The appearance-related pressure people feel from their peers to change or improve their own physical appearance (Jones & Crawford 2006, p.259). Therefore, when operationalizing the construct, a measurement for peer pressure with regards to physical appearance was used. Table 3 illustrates the conceptual definitions of the variables in this study. The scales used to measure these variables were modified according to the context of the study, Egyptian culture and the comments made by the participants (see Table 5 for operational definitions). Table 3 - Conceptual Definitions of Research Variables Variable Conceptual Definition Social Media Influence “Socio-cultural channel through which ideals of beauty are transmitted to members of society (Tiggemann, 2011, p.759) Family Influence “The degree to which the family is concerned with physical appearance and attractiveness” (Davis, Shuster, Blackmore & Fox, 2004, p.139) “Represents the home and family environment which place an important influence on physical appearance (Curtis & Loomans, 2014, p.41) Peer Influence “Refers to the appearance-related social pressure people feel from their peers to change or improve their own physical appearance (Jones & Crawford 2006, p.259). “Peers exert powerful socialization effects on behaviours and attitudes of individuals” (Brechwald & Prinstein, 2011, p.168) Religiosity “The degree to which convictions about religion are felt to be a central and essential element of the self” (Putney & Middleton 1961, p.286) Internalization of Appearance Ideals “The extent to which an individual cognitively subscribe to socially defined ideals of attractiveness, incorporates these standards into one’s personal belief system and commits to behaviours intended to produce an approximation of these ideals” (Thompson & Stice, 2001, p181) 99 Table 3 continuation Appearance Comparison “Comparison to individuals perceived to be more or less physically attractive than the individual” (Ridolfi, Myers, Crowther & Ciesla, 2011, p.492) Self-Surveillance “The habitual monitoring of women to themselves to ensure compliance with societal beauty ideals” (McKinley & Hyde 1996, p.183) Materialism “The importance ascribed to the ownership and acquisition of material goods in achieving major life goals” (Richins, 2004, p. 210) Attitudes towards Cosmetic Surgery “The degree to which individuals accept cosmetic surgery based on the motivation of having it done, focusing on two sources of motivation: social reasons and intrapersonal reasons” (Henderson-king & Henderson-king, 2005, p.138) Facial Appearance Concerns “Feeling of dissatisfaction with facial appearance and motives of changing aspects of the face, hair, and skin” (Fardouly & Rapee, 2019, p.128) Behavioural Intentions “Intentions are indications of how hard people are willing to try, of how much of an effort they are planning to exert, in order to perform the behaviour” (Ajzen, 1991, p.181) The second step was to find suitable measurements for the constructs under study. For each variable, the most widely used measurements were selected and compared against each other in terms of publication date, reliability and validity, citations, and its various adaptations across its use. Table 4 outlines the various scales that were considered for the questionnaire design. Some scales were chosen from their original scales of the theory used, such as Schaefer et al. (2017), Heinberg et al. (1995), McKinley and Hyde (1996), and Richins (2004). In the case of religiosity, two measurements were taken into consideration: Hoge (1972) and Burroughs and Rindfleisch (2002). Hoge (1972) scale measures the intrinsic and extrinsic religiosity, while Burroughs and Rindfleisch (2002) scale measures the importance of religion in one’s life, the scale is adapted from one of four scales Putney and Middleton (1961) offered for measuring the dimensions of religious ideology. Burroughs and Rindfleisch (2002) scale were found to be more general, fitting to the context of the study and effectively measured the conceptual definition of religiosity. Hence, it was chosen. Other scales were found to be related to the research objectives and were adapted from studies of cosmetic surgery consumption, appearance-focused behaviours, and body image. For example, measurement of Attitudes towards CS and Behavioural Intentions were chosen from studies of cosmetic surgery and appearance-focused behaviours; Henderson-King and Henderson-King (2005) and Davis and Vernon (2002). Measurements of Sociocultural Influences (social media, peer, and family) and Facial Appearance Concerns were chosen from studies of body image; Schaefer et al. (2017); Chen et al . (2006). According to the conceptual definitions of social media influence, peer influence and family influence, the scales were chosen accordingly. As discussed in the earlier paragraph, peer influence was 100 conceptualized in terms of appearance-focused social pressure from peers. Various scales were considered for the measurement of Peer and Family Influence, e.g., Davis et al. (2004) family focus on appearance scale and Jones et al. (2004) peer influence scale which consisted of 3 subscales: appearance conversations with friends, perception of teasing scale for friends and peer attributions about the importance of weight and shape regarding popularity. We focused on Schaefer et al.’s (2017) Sociocultural Attitudes towards Appearance scale as it was found to be brief and adequately measure the sociocultural constructs. For materialism two scales were taken into consideration: Richins (2004) and Goldberg et al . (2003). The material values scale developed by Richins (2004) is the shortened version of Richins and Dawson (1992) scale, which is used to examine materialism as a facet of consumer behaviour. Richins (2004) scale was chosen for this study as it is designed to assess materialism at a general level, not focused on youth as Goldberg et al . (2003) scale. For the Appearance Focused Social Comparison scale, it was adapted from the following two scales: the Physical Appearance Comparison Scale (PACS) developed by Thompson et al. (1991), and the Iowa-Netherlands Comparison Orientation Measure developed by Gibbons and Buunk (1999). The researcher used both scales to adequately measure the construct and to better address the objective of the study. A detailed description of the operational definitions of the variables is illustrated in Table 5; where the adaptations done for every scale are explained. As will be further clarified, the adaptations were done for the questions to be clearer and easier for the respondent to answer. Table 4 - Measurement Selection Construct Measurements that were considered for instrument design Scale used for measurement Social Media Influence Socio cultural Attitudes towards Appearance Questionnaire-4-Revised (SATAQ-4R) Schaefer et al. (2017) Socio cultural Attitudes towards Appearance Questionnaire-4-Revised (SATAQ-4R) Schaefer et al. (2017) Family Influence Family Focus on Appearance Davis et al. (2004) Socio cultural Attitudes towards Appearance Questionnaire-4-Revised (SATAQ-4R) Schaefer et al. (2017) Socio cultural Attitudes towards Appearance Questionnaire-4-Revised (SATAQ-4R) Schaefer et al. (2017) 101 Table 4 continuation Peer Influence Jones et al. (2004) Socio cultural Attitudes towards Appearance Questionnaire-4-Revised (SATAQ-4R) Schaefer et al. (2017) Socio cultural Attitudes towards Appearance Questionnaire-4-Revised (SATAQ-4R) Schaefer et al. (2017) Religiosity Religious Importance Scale Burroughs and Rindfleisch (2002) Intrinsic Motivation Scale Hoge’s (1972) Religious Importance Scale Burroughs and Rindfleisch (2002) Internalization of Appearance Ideals Socio cultural Internalization of Appearance Questionnaire Keery et al. (2004) The Socio cultural Attitudes towards Appearance Questionnaire (SATAQ) Heinberg et al. (1995) The Socio-cultural Attitudes towards Appearance Questionnaire (SATAQ) Heinberg et al. (1995) Appearance Comparison Physical Appearance Comparison Scale (PACS) Thompson et al. (1991) The Iowa-Netherlands Comparison Orientation Measure Gibbons and Buunk (1999) Physical Appearance Comparison Scale (PACS) Thompson et al . (1991) The Iowa-Netherlands Comparison Orientation Measure Gibbons and Buunk (1999) Self-surveillance Surveillance Scale McKinley and Hyde (1996) Surveillance Scale McKinley and Hyde (1996) Materialism Material Values Scale Richins (2004) Youth Materialism Scale Goldberg et al. (2003) Material Values Scale Richins (2004) Attitudes towards cosmetic surgery Acceptance of Cosmetic Surgery Henderson-King and Henderson-King (2005) Acceptance of Cosmetic Surgery Henderson-King and Henderson-King (2005) Facial Appearance Concerns The Negative Physical Self Scale Chen et al. (2006) The Negative Physical Self Scale Chen et al. (2006) Behavioural Intentions Measures of Use of Cosmetic Surgeries/Procedures Davis and Vernon (2002) Measures of Use of Cosmetic Surgeries/Procedures Davis and Vernon (2002) The original scale of Sociocultural Attitudes Toward Appearance Questionnaire-4 (SATAQ-4) developed by Schaefer et al. (2017) is a measure of internalization of appearance ideals (i.e., personal acceptance of societal ideals) and appearance-related sociocultural pressures (i.e., pressures to achieve the societal ideal). The scale is a 7-factor 31-item scale, labelled the SATAQ-4R-Female: (1) Internalization: Thin/Low Body Fat, (2) Internalization: Muscular, (3) Internalization: General Attractiveness, (4) Pressures: Family, (5) Pressures: Media, (6) Pressures Peers, and (7) Pressures: Significant Others. The scale is a five-point 102 Likert scale with response options of 1 (definitely disagree), 2 (mostly disagree), 3 (neither agree nor disagree), 4 (mostly agree), and 5 (definitely agree). In this study, the sociocultural influences (social media, peer, and family), were adapted from the study of Schaefer et al. (2017), the three dimensions of appearance-related sociocultural pressures emanating from peers, family, and media via the Pressures: Peers, Pressures: Family, and Pressures: Media subscales were used. The scale is a 12 item (4 items for each construct). The original scale focused on social pressures for Thin/Low Body Fat, whereas this study focuses on general physical appearance (see original scale in Appendix). Hence, two items for each construct were modified. For example, “I get pressure from my peers to decrease my level of body fat” was modified into “I feel pressure from friends to look attractive” and “My peers encourage me to get thinner” was modified to “My friends encourage me to follow beauty ideals/standards”. The same was applied for the other two constructs: family and social media influence. Moreover, the word “media” was replaced with “Instagram” in the social media dimension, as the aim of this research is to study the effect of social media and particularly Instagram on Egyptian women. A 5-point Likert scale was used with a slight change in the wordings of the original scale; 1 (strongly disagree), 2 (disagree), 3 (neither agree nor disagree), 4 (agree), and 5 (strongly agree) in order for the questionnaire to be harmonised. Regarding the second variable, religiosity, it was measured using a five item, 5-point Likert scale, from “strongly disagree” to “strongly agree”. Questions were adapted from the study of Burroughs and Rindfleisch (2002). The reverse-coded item “Religion is a subject in which I am not particularly interested” was excluded from the scale as it was suggested in the pilot that it sometimes confuses respondents. In fact, it is common for respondents to answer them wrong which reduces the reliability of the scale (Krosnick & Presser, 2010). A few wordings were changed as they confused most of the respondents in the pilot study, e.g., the statement “Were I to think about religion differently, my whole life would be very different” was modified to “If I think about religion differently, my whole life would be very different”. Also, the statement “My ideas on religion have a big influence on my views in other areas” was modified to “My religious beliefs have a big influence on my views and actions” as it was clearer for respondents. Internalization of appearance ideals was measured using five item, 5-point Likert scale, from “strongly disagree” to “strongly agree”. Questions were adapted from the study of Heinberg et al. (1995). However, all the items of the scale were adapted to the context of the study. The scale measures internalization of appearance ideals through mass media (TV and magazines), hence, the scale for this study was modified to social media instead of conventional media. For example, the statement “Women who appear in TV 103 shows and movies project the type of appearance that I see as my goal” was modified to “Women who appear in social media project the type of appearance that I see as my goal”. Moreover, the scale focused on the internalization of thin beauty ideals, whereas this study aims to measure the internalization of beauty ideals in general. Hence, the statement “Photographs of thin women make me wish that I were thin” was changed to “Photographs of airbrushed/flawless women make me wish to look like them”. Also, the statement “Wish I looked like a swimsuit model” was modified to “Wish I looked like celebrities/influencers on social media”. Appearance comparison was measured using six item, 5-point Likert scale, from “strongly disagree” to “strongly agree”. Three items were adapted from the study of Thompson et al. (1991) Physical Appearance Comparison Scale (PACS) and the other three items were adapted from the study of Gibbons and Buunk (1999) which is a general social comparison scale (see original scales in Appendix). Hence, the items of Gibbons and Buunk (1999) scale were adapted to comparisons that are focused on physical appearance. For example, “I often try to find out what others think who face similar problems as I face” was modified to “I often relate to women who have insecurities about their looks and try to find out how they deal with them”. Also, the statement “If I want to learn more about something, I try to find out what others think about it” was modified to “If I want to learn more about a cosmetic procedure, I try to find out what others think about it”. Self-surveillance was measured using seven item, 5-point Likert scale, from “strongly disagree” to “strongly agree”. The Surveillance Scale is a part of the Objectified Body Consciousness Scale adapted from the study of McKinley and Hyde (1996). The statement “During the day, I think about how I look many times” was excluded from the scale to shorten the scale and allow the research to include more variables. Moreover, the statement “I think it is more important that my clothes are comfortable than whether they look good on me” confused many respondents during the pilot study and was modified to “I often think of my looks rather than my comfort in clothing”. Materialism was measured using nine item, 5-point Likert scale, from “strongly disagree” to “strongly agree”. The Material Value Scale is adapted from the study of Richins (2004), where the pilot study undertaken revealed that people was confused with the wording of the statement “I try to keep my life simple, as far as possessions are concerned” so it was modified to “I try to keep my life simple when it comes to possessions”. Regarding the Attitudes towards CS, the Acceptance of Cosmetic Surgery Scale (ACSS) was adapted from Henderson-King and Henderson-King (2005). The original scale encompasses a three-component model (Interpersonal, Social and Consider) that examine the ways in which personal experiences, individual differences and social and cultural factors are related to people’s acceptance of cosmetic surgery as 104 seen in (Table 5). The ACSS is originally a 15-item measure with a 5-point Likert scale, from “strongly disagree” to “strongly agree”. However, the number of items was reduced to 12 by dropping repetitive items in each subscale. Moreover, the word “cosmetic surgery” was replaced with “cosmetic procedures” as the current research assesses attitudes about surgical and non-surgical procedures used to change physical appearance. The Facial Appearance Concerns scale was measured using eight items, 5-point Likert scale from “Never” to “Always”. The Negative Physical Self Scale adapted from Chen et al . (2006) consists of five dimensions: Fatness concern, shortness concern, facial appearance concern, thinness concern & general appearance concern. The current study used the facial appearance concern dimension, where three items were excluded after the pilot study, e.g., the statement “Others are not satisfied with the way my face appears” was excluded as it was very similar to the statement “People around me do not like the way my face looks”. Furthermore, some wordings were changed after the pilot study to better fit the Egyptian culture, as the original study was conducted with a Chinese sample. For example, the word “depressed” was replaced with “concerned” and the word “ashamed” was changed to “bothered”. Regarding the Behavioural Intentions to undergo cosmetic procedures, participants were asked if they have ever had or wanted to have different kinds of cosmetic procedures or activities/techniques to enhance their physical/sexual attractiveness. Participants were asked about a set of surgical and nonsurgical procedures (as seen in Table 5), for each procedure, participants could respond either (1) “I have done this,” (2) “I would like to do this now, if I could,” (3) “I plan to do this in the future when I have the money,” (4) “I plan to do this in the future when or if I need it,” or (5) “I never plan to do this under any circumstances.” The visual presentation of the survey is important especially for internet questionnaires to ensure a high level of response. Hence, the researcher worked on making the survey visually appealing to encourage the respondent to fill it in, while not appearing too long. The final version of the survey was nine pages long on a computer/mobile screen with either one/two question/s per page or one section per page. The survey consisted of a single column and matrix type questions, which helped reduce the apparent length of the questionnaire without reducing legibility. The survey was mobile-friendly, and it was easy to navigate through the questions. Using the cloud-based survey software (Qualtrics) helped design a professional-looking survey, as it gives the ability to customize the appearance of the survey in many different ways. It contains a series of style templates for typefaces, colours, and page layout, as well as optimisation routines for screen, tablet, and mobile phone. 105 Table 5 - Operationalisation of Variables Construct Items Adapted from Social media influence 1-I feel pressure from Instagram to improve my appearance 2-I feel pressure from Instagram to look attractive 3-I feel pressure from Instagram to look in better shape 4-I feel pressure from Instagram to follow beauty ideals/standards (e.g., makeup, skincare, hair care, body, etc.) Schaefer et al. (2017) Peer influence 1-I feel pressure from my friends to improve my appearance 2-I feel pressure from friends to look attractive 3-My friends encourage me to look in better shape 4-My friends encourage me to follow beauty ideals/standards (e.g., makeup, skincare, hair care, body, etc.) Schaefer et al. (2017) Family influence 1-I feel pressure from family members to improve my appearance 2-I feel pressure from family members to look attractive 3-Family members encourage me to look in better shape 4-Family members encourage me to follow beauty ideals/standards (e.g., makeup, skincare, hair care, body, etc.) Schaefer et al. (2017) Religion 1My religion is one of the most important parts of my philosophy of life. 2My religious beliefs have a big influence on my views and actions. 3My religion forms an important basis for the kind of person I want to be. 4If I think about religion differently, my whole life would be very different 5I often think about religious matters Burroughs and Rindfleisch (2002) Internalization of Appearance Ideals 1Women who appear in social media project the type of appearance that I see as my goal 2I tend to compare my looks to women on social media 3Photographs of airbrushed/flawless women make me wish to look like them 4I wish I looked like celebrities/influencers on social media 5I often check social media and compare my appearance to celebrities/influencers. Heinberg et al. (1995) 106 Table 5 continuation Appearance Comparison 1-I often compare how I am dressed to how other women are dressed 2-If I want to find out how good-looking/attractive I am, I compare my looks with other women (e.g., friends, acquaintances, peers, etc.). 3-I often compare my figure to other women with respect to face, skin, hair, and/or body fit. Thompson et al . (1991) 4-I often like to talk with other women (e.g., friends, family, acquaintances, etc.) about mutual beauty tips, opinions, and experiences 5-I often relate to women who have insecurities about their looks and try to find out how they deal with them 6-If I want to learn more about cosmetic procedure, I try to find out what other women think about it Gibbons and Buunk (1999) SelfSurveillance 1I often think about how I look 2I often think of my looks rather than my comfort in clothing 3I think more about how my body looks than how my body feels. 4I often compare how I look with how other people look. 5I often worry about whether the clothes I am wearing make me look good. 6I am more concerned about how my body looks than what my body can do. 7I often worry about how I look to other people. McKinley and Hyde (1996) Materialism 1I admire people who own expensive homes, cars, and clothes 2The things I own say a lot about how well I’m doing in life. 3I like to own things that impress people 4I try to keep my life simple when it comes to possessions. 5Buying things gives me a lot of pleasure. 6I like a lot of luxury in my life. 7My life would be better if I owned certain things I don’t have 8I’d be happier if I could afford to buy more things 9It sometimes bothers me quite a bit that I can’t afford to buy all the things I’d like Richins (2004) 107 Table 5 continuation Attitudes towards CS Interpersonal subscale 1It makes sense to have a minor cosmetic procedure rather than spending years feeling bad about the way you look 2Cosmetic procedure is a good thing because it can help people feel better about themselves 3If cosmetic procedures can make someone happier with the way they look, they should try it 4Cosmetic procedures can be a benefit to people's self-image Social subscale 1I would think about having cosmetic procedures in order to keep looking young 2If it would benefit my career, I would think about having cosmetic procedures 3I would seriously consider having cosmetic procedures if I thought my partner would find me more attractive 4If a simple cosmetic procedure would make me more attractive to others, I would think about trying it Consider subscale 1If I could have a cosmetic procedure done for free, I would consider trying cosmetic procedures 2If I knew there would be no negative side effects or pain, I would like to try cosmetic procedures 3I have sometimes thought about having cosmetic procedures 4In the future, I could end up having some kind of cosmetic procedure HendersonKing and HendersonKing (2005) Facial Appearance Concerns 1I am concerned about how my face looks 2If there is a way I can improve my facial appearance, I will consider doing it 3I am bothered about one or more of my facial features 4People around me do not like the way my face looks 5I would consider having cosmetic procedures, whether surgical (e.g., nose job) or non-surgical (fillers/Botox) 6My friends do not like how my face looks 7The people I like most do not like the way my face looks 8I do not like what I see when I look in the mirror Chen et al. (2006) Behavioural Intentions Participants were asked: “Have you ever had or wanted to have the following kinds of surgery or other activities/techniques to enhance your physical/sexual attractiveness?” (1) Non-Surgical procedures for enhancing the face and hair (permanent makeup, hair restoration/transplants, fillers, Botox, chemical peel, laser peel, microneedling, dermabrasion, teeth whitening, veneers) (2) Surgical procedures for enhancing the face (nose reshaping, eyelid lift, eye bag removal surgery, surgical facelift, neck lift, brow lift, forehead lift, chin implants, chin augmentation surgery) Davis and Vernon (2002) 114 confirm their willingness to fill out the questionnaire, conforming to the voluntary nature of participation. Access to online communities on social media, e.g., WhatsApp or Facebook groups was obtained by contacting the moderators of the groups and taking their permission to send a link to the questionnaire. This was done to gain their consent and to respect the privacy of these groups. The participants in questionnaires were not harmed, embarrassed, or annoyed by the data collection process. All data gathered was reviewed and handled in confidence, respondents remained anonymous, and all completed questionnaires were stored safely with the researcher, with only the people who are working on this research having access to the information provided. 4.9. Conclusion In this chapter, the methodology of this research was presented. It could be concluded that the philosophical stance of this research is positivism, and the purpose of the research is descriptive in nature. The research strategy used a deductive approach, and a quantitative method is followed where the type of investigation is achieved using preliminary analysis, sample profile, confirmatory factor analysis, and structural equation modelling. The researcher interference was minimal, and data was collected using internet questionnaires using self-selection sampling technique. The eligible sample of respondents was young and middle-aged Egyptian women aging 18 to 60 years. The sample size was 529 respondents. Finally, the research time horizon was cross sectional. 115 CHAPTER 5 - DATA ANALYSIS AND RESULTS 5.1. Overview After identifying the methodology choices, the current chapter aims to test the research model and present the results of the empirical study. As mentioned in the previous chapter, data collection was performed with Qualtrics software (2017) whereby the questionnaire was created and distributed online. The next step was to import data from Qualtrics to the specific software used in the analysis, namely SPSS statistics program and AMOS software package (Version 27). Data analysis process starts by preliminary data analysis and normality tests. Next the sample profile is presented. Subsequently, the research hypothesis is tested using Structural Equation Modelling (SEM) technique. First, the measurement model is specified and assessed through Confirmatory Factor Analysis (CFA), with the aim of providing a confirmatory test of the measurement theory developed and further refine and validate the measured variables. Second, a structural model is specified to estimate the relationships between the constructs that are present in the research model. Thus, this chapter examines the research hypotheses and analyses data in an attempt to answer the research questions. Figure 11 displays the outline for this chapter. Figure 11 - Chapter Five Outline 5.2. Preliminary Data Analysis As mentioned before, the population of the present study corresponds to young and middle-aged Egyptian women aged 18 to 60 years who have an Instagram account. To conduct the survey with this particular population, filter questions were asked to determine respondent’s eligibility; the first question was to 5.3 Sample Profile 5.4 Measurement Model Analysis 5.6 Structural Model Analysis 5.1 Overview 5.2 Preliminary Data Analysis Data Analysis and Findings 5.5 Second Order Model CFA 5.7 Hypothesis Testing 5.8 Conclusion 116 specify the gender of the participant to exclude male participants from the survey, and the second question asked if participants have an Instagram account to discount participants who do not have an Instagram account from the survey. From that population, the survey was initially sent to a sample of 870 participants. The link for the web survey was sent via social media networks (Facebook, Instagram, and WhatsApp). Participants were asked if they are willing to participate in the PhD research. Those who agreed were given a brief description of the survey process and were sent a hyperlink to the Qualtrics survey. Considering those who did not complete the questionnaire (either male participants or respondents who do not have an Instagram account) or partially answered or just did not submit the survey, a total of 529 valid questionnaires were submitted and recorded in the Qualtrics platform. Preliminary data analysis examines the data and prepare it for further analysis. The first steps are missing data analysis and outlier detection which are attempted to clean the data to a format most suitable for multivariate analysis. Then describe the key features of the data with several descriptive statistics and normality tests. 5.2.1. Data Preparation: Missing Data and Outliers As an initial step, the data was checked for missing values. The survey was conducted through Qualtrics software which enabled a force response on all questions, henceforth there was no missing values. A total of 529 respondents have answered the respective items in the questionnaire, otherwise the respondents could not proceed with filling the questionnaire. Secondly, the existence of outliers and their impact was analysed. The outliers correspond to observations that are distinctively different from the other observations present in the analysis (Hair et al., 2010, p.64). With the help of scatter plots computed for each variable, it was possible to verify the existence of some observations different from the general distribution of the data. However, the different observations that would be considered outliers did not have an influence on the mean; the difference between the original mean and the 5% Trimmed mean of these observations was negligible. Hence these outliers were retained in the sample under study. 5.2.2. Descriptive Analysis and Normality Tests The data analysis proceeded with several descriptive analysis and normality tests for the variables present in the proposed model. Table 7 provides a summary of the variables that will be addressed in the present chapter. The number of observations is the same for each variable, corresponding to 529 participants. To describe the data, the mean was calculated to indicate the value of each variable among all observations. The standard deviation was computed as well, which shows how much these observations 117 diverge, in average. For normality tests, the values of skewness and kurtosis are presented to illustrate the shape of data. The skewness provides an indication of the symmetry of the distribution. While the kurtosis provides information about the “peakedness” of the distribution (Pallant, 2020). Normality was also verified by the Kolmogorov-Smirnov and the Shapiro-Wilk tests (Hair et al., 2010). The descriptive analysis and normality tests of sociocultural variables are presented in Table 8. The descriptive statistics and normality tests of the remaining variables that are included in the proposed model are presented in Table 9. Table 7 - Research Model Variables Construct Dimensions Name Sociocultural Social media influence SMI Peer influence PI Family influence FI Psychological mechanisms Internalization of appearance ideals INTRN Appearance comparison APPCOMP Self-concept Self-surveillance SS Materialism MATRLSM Religion Individual religiosity RLG Attitudes towards CS (ATTCS) Interpersonal INTERP Social SOCIAL Consider CONSDR Facial Appearance Concerns Facial dissatisfaction FACL Behavioural Intentions Behavioural intention towards cosmetic procedures BICP 118 Table 8 - Sociocultural Variables: Descriptive Statistics and Normality Tests Variables Mean Standard deviation Skewness Kurtosis KolmogorovSmirnov Shapiro-Wilk Statistic Sig Statistic Sig SMI1-I feel pressure from Instagram to improve my appearance 2.88 1.193 -.004 -1.102 .202 .000 .898 .000 SMI2I feel pressure from Instagram to look attractive 2.84 1.216 .077 -1.149 .217 .000 .893 .000 SMI3-I feel pressure from Instagram to look in better shape 3.12 1.214 -.286 -1.084 .258 .000 .879 .000 SMI4-I feel pressure from Instagram to follow beauty ideals/standards 2.89 1.172 -.045 -1.123 .215 .000 .891 .000 PI-I feel pressure from my friends to improve my appearance 2.19 1.006 .794 .144 .283 .000 .852 .000 PI2I feel pressure from my friends to look attractive 2.11 .988 .895 .315 .298 .000 .832 .000 PI3I feel pressure from my friends to look in better shape 3.10 1.107 -.380 -.810 .240 .000 .884 .000 PI4My friends encourage me to follow beauty ideals/standards 2.98 1.090 -.298 -.876 .215 .000 .889 .000 FII feel pressure from family members to improve my appearance 2.34 1.165 .600 -.584 .242 .000 .872 .000 FI2I feel pressure from family members to look attractive 2.19 1.114 .818 -.181 .276 .000 .842 .000 FI3-I feel pressure from family members to look in better shape 3.45 1.065 -.747 -.141 .302 .000 .852 .000 FI4-I Family members encourage me to follow beauty ideals/standards 2.64 1.120 .169 -.955 .211 .000 .899 .000 119 Table 9 - Remaining Model Variables: Descriptive Statistics and Normality Tests Variables Mean Standard deviation Skewness Kurtosis KolmogorovSmirnov Shapiro-Wilk Statistic Sig Statistic Sig RLG1-My religion is one of the most important parts of my philosophy of life 4.01 .923 -1.067 1.261 .280 .000 .818 .000 RLG2-My religious beliefs have a big influence on my views and actions 3.95 .910 -.905 .813 .284 .000 .835 .000 RLG3-My religion forms an important basis for the kind of person I want to be. 4.00 .924 -1.109 1.403 .291 .000 .813 .000 RLG 4-If I think about religion differently, my whole life would be very different 3.39 1.156 -.333 -.767 .215 .000 .903 .000 RLG5-I often think about religious matters 3.71 .956 -.647 .028 .282 .000 .866 .000 INTRN1-Women who appear in social media project the type of appearance that I see as my goal 2.80 .979 -.019 -.409 .217 .000 .905 .000 INTRN2-I tend to compare my looks to women on social media 2.71 1.115 .115 -1.008 .217 .000 .895 .000 INTRN3-Photographs of airbrushed/ flawless women make me wish to look like them 2.89 1.164 -.086 -1.081 .209 .000 .895 .000 INTRN4-I wish I looked like celebrities/influencers on social media 2.74 1.103 .152 -.928 .221 .000 .899 .000 INTRN5-I often check social media and compare my appearance to celebrities/influencers 2.42 1.078 .409 -.688 .237 .000 .888 .000 APPCOMP1-I often compare how I am dressed to how other women are dressed 3.17 1.108 -.340 -.920 .264 .000 .876 .000 120 Table 9 continuation APPCOMP2-If I want to find out how good-looking/attractive I am, I compare my looks with other women 2.48 1.106 .417 -.780 .256 .000 .882 .000 APPCOMP3-I often compare my figure to other women with respect to face, skin, hair, and/or body fit 2.99 1.147 -.216 -1.065 .237 .000 .884 .000 APPCOMP4I often like to talk with other women about mutual beauty tips, opinions, and experiences 3.67 1.025 -.775 .047 .304 .000 .851 .000 APPCOMP5I often relate to women who have insecurities about their looks and try to find out how they deal with them 3.03 1.134 -.103 -.915 .199 .000 .907 .000 APPCOMP6If I want to learn more about cosmetic procedure, I try to find out what other women think about it 3.47 1.035 -.770 -.055 .309 .000 .846 .000 SS1-I often think about how I look 3.80 .833 -.819 .879 .326 .000 .825 .000 SS2-I often think of my looks rather than my comfort in clothing 2.79 1.148 .195 -.991 .234 .000 .895 .000 SS3-I think more about how my body looks than how my body feels 3.11 1.136 -.139 -1.071 .241 .000 .885 .000 SS4-I often compare how I look with how other people look 2.74 1.073 .188 -.889 .233 .000 .894 .000 SS5-I often worry about whether the clothes I am wearing make me look good 3.72 .958 -.888 .368 .338 .000 .820 .000 SS6am more concerned about how my body looks than what my body can do 3.09 1.118 -.122 -.950 .217 .000 .900 .000 SS7-I often worry about how I look to other people 3.10 1.130 -.210 -.938 .229 .000 .897 .000 121 Table 9 continuation MATRLSM1-I admire people who own expensive homes, cars, and clothes 2.54 1.118 .308 -.755 .208 .000 .901 .000 MATRLSM2-The things I own say a lot about how well I’m doing in life. 2.64 1.133 .260 -.889 .226 .000 .898 .000 MATRLSM3-I like to own things that impress people 2.42 1.060 .360 -.730 .231 .000 .889 .000 MATRLSM4-I try to keep my life simple when it comes to possessions. 3.56 .875 -.442 -.101 .275 .000 .870 .000 MATRLSM5-Buying things gives me a lot of pleasure. 3.89 .939 -1.027 1.142 .304 .000 .825 .000 MATRLSM6-I like a lot of luxury in my life. 3.25 1.001 -.152 -.616 .206 .000 .904 .000 MATRLSM7-My life would be better if I owned certain things I don’t have 2.62 1.068 .307 -.686 .231 .000 .899 .000 MATRLSM8-I’d be happier if I could afford to buy more things 3.03 1.164 -.110 -1.024 .215 .000 .900 .000 MATRLSM9-It sometimes bothers me quite a bit that I can’t afford to buy all the things I’d like 2.96 1.118 -.051 -1.001 .208 .000 .898 .000 INTERP1-It makes sense to have a minor cosmetic procedure rather than spending years feeling bad about the way you look 3.42 1.191 -.648 -.369 .243 .000 .873 .000 INTERP2-Cosmetic procedure is a good thing because it can help people feel better about themselves 3.51 1.023 -.754 .202 .277 .000 .863 .000 INTERP3-If cosmetic procedures can make someone happier with the way they look, they should try it 3.74 .958 -1.005 1.214 .295 .000 .831 .000 INTERP4-Cosmetic procedures can be a benefit to people's self-image 3.68 .909 -.923 1.041 .310 .000 .834 .000 122 Table 9 continuation SOCIAL1-I would think about having cosmetic procedures in order to keep looking young 2.95 1.228 -.169 -1.065 .204 .000 .898 .000 SOCIAL2-If it would benefit my career, I would think about having cosmetic procedures 2.63 1.257 .234 -1.102 .197 .000 .892 .000 SOCIAL3-I would seriously consider having cosmetic procedures if I thought my partner would find me more attractive 2.65 1.239 .178 -1.080 .182 .000 .897 .000 SOCIAL4-If a simple cosmetic procedure would make me more attractive to others, I would think about trying it 2.74 1.220 .095 -1.052 .176 .000 .904 .000 CONSDR1-If I could have a cosmetic procedure done for free, I would consider trying cosmetic procedures 2.69 1.219 .159 -1.014 .180 .000 .904 .000 CONSDR2-If I knew there would be no negative side effects or pain, I would like to try cosmetic procedures 3.17 1.303 -.320 -1.045 .222 .000 .890 .000 CONSDR3-I have sometimes thought about having cosmetic procedures 3.18 1.248 -.541 -.906 .283 .000 .851 .000 CONSDR4-In the future, I could end up having some kind of cosmetic procedure 3.17 1.200 -.529 -.682 .234 .000 .872 .000 FACL1I am concerned about how my face looks 3.67 1.044 -.344 -.432 .202 .000 .878 .000 FACL2-If there is a way I can improve my facial appearance, I will consider doing it 3.43 1.212 -.328 -.698 .170 .000 .893 .000 FACL3-I am bothered about one or more of my facial features 2.73 1.240 .203 -.858 .160 .000 .904 .000 FACL4-People around me do not like the way my face looks 1.56 .833 1.576 2.389 .361 .000 .695 .000 123 Table 9 continuation FACL5-I would consider having cosmetic procedures, whether surgical or non-surgical 2.26 1.267 .609 -.736 .239 .000 .842 .000 FACL6-My friends do not like how my face looks 1.32 .676 2.582 7.600 .449 .000 .531 .000 FACL7-The people I like most do not like the way my face looks 1.35 .739 2.383 5.724 .450 .000 .539 .000 FACL 8-I do not like what I see when I look in the mirror 1.99 1.053 .688 -.462 .271 .000 .817 .000 BICP1-Have you ever had or wanted to have the following non-surgical techniques to enhance the face 3.1471 .83638 -.226 -.713 .081 .000 .979 .000 BICP2-Have you ever had or wanted to have the following surgical techniques to enhance the face 4.4197 .67080 -1.583 2.937 .196 .000 .816 .000 As illustrated in the previous tables, the distribution of each variable was analysed to verify that the variables follow a normal distribution (Hair et al., 2010). According to the Kolmogorov-Smirnov test of normality, it assumes the data to be normal if the P-value is greater than 0.05. According to the Kolmogorov-Smirnov Test in this case, it is possible to violate the assumptions of normality as the Sig. value is 0.000 for each variable. The Shapiro-Wilk test also indicates the nonnormality of the distribution of the variables. Nonetheless, any issue emerging from the non-normality of the data is mitigated by the sample size. 5.3. Sample Profile The sample of the present study is constituted of Egyptian women between the age of 18-60 years. Five hundred and twenty-nine questionnaires were valid responses and eligible for the analysis. The characteristics of the respondents were analysed in terms of two different dimensions: i) Individual’s demographics ii) Individual’s Instagram usage. First, the sample characterization is described according to individuals’ gender, age, educational level, marital status, religion, current occupation, personal income, number of people in the household and household income. Table 10 presents detailed information of the sample demographics. The analysis indicated that in terms of age, most of the respondents were between 25 to 34, and of 35 to 44 years of age. Those two segments correspond to 130 measurement items, materialism by nine measurement items, and behavioural intention indicated by two measurement items. This allows an over-identification of the model under analysis (each construct has four or more items) (Hair et al., 2014). All the measures are reflective, which means that “the direction of causality is from the latent construct to the measured items” (Hair et al., 2014). The visual representation of the measurement model is then presented in Figure 12. After specifying the constructs, an initial measurement model was developed to be tested. The maximum likelihood method of estimation was applied to show the factor loading for each variable and the model fit. All constructs were allowed to correlate freely, and the measurement items are loading to the respective construct. The errors were also specified for each measurement variable. At this point, the measurement model validity was assessed, considering the model fit and the criteria for construct validity. The initial measurement model had the following values of the goodness of fit indices: χ2/df=2.599; GFI=0.736; AGFI=0.709; NFI=0.736; TLI=0.805; CFI=0.818; RMR=0.99 and RMSEA=0.55. The values suggested that the model fit could be improved. Since it was important to achieve a better fit to proceed the analysis, a re-specification of the model was conducted. The obtained values of the initial measurement model are depicted in Table 12. Table 12 - Summary of Goodness-of-fit Measures Measures X2 /df GFI AGFI NFI TLI CFI RMR RMSEA Initial 2.599 0.736 0.709 0.736 0.805 0.818 0.99 0.55 Threshold < 3 (ρ<.05) > 0.90 > 0.90 > 0.90 > 0.95 > 0.90 < 0.09 < 0.08 X2–Chi-square; GFI–Goodness of Fit Index; AGFI–Adjusted Goodness of Fit; NFI–Normed Fit Index; TLI–Tucker Lewis Index; CFI–Comparative Fit Index; RMR–Root Mean Square Residual; RMSEA–Root Mean Square Error of Approximation 131 Figure 12 - Visual Diagram of the Initial Measurement Model 132 The items were analysed based on the standardized regression weights, some items had factor loadings that were fairly weak (<0.5) and were removed from the model. Other items were also removed to obtain a better fit for the model. Details of the deleted items and the re-specification of the measurement model are shown in Table 13. After deleting the items, the model still had sufficient number of indicators per construct, achieving a just-identified model (3 indicators per construct) (Hair et al., 2014). The next step was accessing the modification indices to improve model fit. The errors of the items presenting highest modification indices were thus correlated. The referred errors correlation was conducted one pair at a time to assure that this strategy is used only when necessary. Table 13 - Iteration of the Measurement Model Construct Items removed Factor Loading < 0.5 Achieving Better Model Fit Peer Influence PI4= 0.417 Family Influence FI3= 0.431 Religion RLG4= 0.316 RLG2=0.881 Appearance comparison APP4= 0.194 APP5= 0.485 APP6= 0.192 Self-surveillance SS1= 0.463 SS2=0.557 SS3=0.674 SS4=0.605 Materialism MTRLSM2= 0.485 MTRLSM6 =0.494 MTRLSM4= 0.194 MTRLSM1=0.611 MTRLSM5= 0.411 MTRLSM3=0.598 Facial appearance concerns FACL1= 0.210 FACL8=0.540 FACL2= 0.234 FACL3= 0.407 FACL5= 0.286 Internalization of appearance ideals INTRN2=0.782 INTRN5=0.789 Attitude towards CS INTERP1=0.730 SOCIALl1=0.786 CONSDR1=0.758 133 The metrics fit of the final iteration model improved to CMIN/DF = 1.367; GFI =0.924; AGFI=0.903; NFI=0.925; TLI=0.974; CFI=0.978; RMR=0.044 and RMSEA =0.026, suggesting a good model fit. This was considered the final model, that would proceed to further analysis. The obtained values of the final measurement model are depicted in Table 14. In conclusion, the CFA suggested that the measurement model was acceptable. Therefore, it was considered that the model presented a good fit. The measurement model is presented in Figure 13. Table 14 - Summary of Goodness-of-fit Measures Measures X2 /df GFI AGFI NFI TLI CFI RMR RMSEA Initial 2.599 0.736 0.709 0.736 0.805 0.818 0.99 0.55 Final 1.367 0.924 0.903 0.925 0.974 0.978 0.044 0.026 Threshold < 3 (ρ<.05) > 0.90 > 0.90 > 0.90 > 0.95 > 0.90 < 0.09 < 0.08 X2–Chi-square; GFI–Goodness of Fit Index; AGFI–Adjusted Goodness of Fit; NFI–Normed Fit Index; TLI–Tucker Lewis Index; CFI–Comparative Fit Index; RMR–Root Mean Square Residual; RMSEA–Root Mean Square Error of Approximation In addition, the convergent and discriminant validity of the measurement model were assessed. Following the recommendation of Hair et al. (2014), convergent validity was assessed using factor loadings, construct reliability (CR) and average variance extracted (AVE). The factor loadings had values greater than the recommended threshold (≥ .50) except for the item “Family members encourage me to look in better shape” that had a value of 0.44 and “My friends encourage me to follow beauty ideals/standards” which had a value of 0.43.The eleven constructs showed high levels of construct reliability (≥ .7) and displayed acceptable values for the average variance extracted (≥ .5; Fornell & Larcker, 1981) except for self-surveillance construct which had a value of 0.450. Hence, the values implied an adequate convergent validity. Results of factor loadings, construct reliability, average variance extracted, and Cronbach’s alpha are presented in Table 15. 134 Figure 13 - Measurement Model 135 Table 15 - Confirmatory Factor and Reliability Analysis Construct Standardized factor loading SMI I feel pressure from Instagram to improve my appearance I feel pressure from Instagram to look attractive I feel pressure from Instagram to look in better shape I feel pressure from Instagram to follow beauty ideals/standards 0.914 0.931 0.862 0.752 FI I feel pressure from family members to improve my appearance I feel pressure from family members to look attractive Family members encourage me to follow beauty ideals/standards 0.909 0.921 0.441 PI I feel pressure from my friends to improve my appearance I feel pressure from friends to look attractive My friends encourage me to look in better shape 0.897 0.912 0.445 INTRN Women who appear in social media project the type of appearance that I see as my goal Photographs of airbrushed/flawless women make me wish to look like them I wish I looked like celebrities/influencers on social media 0.563 0.791 0.836 APP I often compare how I am dressed to how other women are dressed If I want to find out how good-looking /attractive I am, I compare my looks with other women I often compare my figure to other women with respect to face, skin, hair, and/or body fit. 0.657 0.776 0.741 SS I often worry about whether the clothes I am wearing make me look good. I am more concerned about how my body looks than what my body can do. I often worry about how I look to other people. 0.652 0.623 0.744 MTRLSM My life would be better if I owned certain things I don’t have I’d be happier if I could afford to buy more things It sometimes bothers me quite a bit that I can’t afford to buy all the things I’d like 0.787 0.833 0.723 RLG My religion is one of the most important parts of my philosophy of life. My religion forms an important basis for the kind of person I want to be. I often think about religious matters 0.831 0.860 0.524 136 Table 15 continuation Construct Standardized factor loading ATTCS-INTERP Cosmetic procedure is a good thing because it can help people feel better about themselves If cosmetic procedures can make someone happier with the way they look, they should try it Cosmetic procedures can be a benefit to people's self-image 0.863 0.869 0.794 ATTCS-SOCIAL If it would benefit my career, I would think about having cosmetic procedures I would seriously consider having cosmetic procedures if I thought my partner would find me more attractive If a simple cosmetic procedure would make me more attractive to others, I would think about trying it 0.774 0.795 0.810 ATTCS-CONSDR If I knew there would be no negative side effects or pain, I would like to try cosmetic procedures I have sometimes thought about having cosmetic procedure In the future, I could end up having some kind of cosmetic procedure 0.787 0.822 0.927 FACL People around me do not like the way my face looks My friends do not like how my face looks The people I like most do not like the way my face looks 0.696 0.887 0.817 BICP Non-surgical Surgical 0.806 0.581 Internal consistency Construct Reliability Average Variance Extracted Cronbach’s Alpha SMI PI FI INTRN APP SS MTRLSM RLG ATTCS-INTERP ATTCS-SOCIAL ATTCS-CONSDR FACL BICP 0.924 0.813 0.820 0.780 0.767 0.713 0.825 0.791 0.880 0.836 0.884 0.845 0.717 0.753 0.611 0.623 0.547 0.525 0.455 0.612 0.568 0.710 0.629 0.718 0.647 0.550 0.922 0.765 0.783 0.768 0.763 0.709 0.821 0.773 0.878 0.838 0.838 0.834 0.721 SMI-social media influence; PI-peer influence; FI-family influence; INTRN-internalization of appearance ideals; APP-appearance comparison; SS-selfsurveillance; MTRLSM-materialism; RLG-religiosity; ATTCS-attitudes towards cosmetic surgery; INTERP-interpersonal attitudes; SOCIAL-social attitudes; CONSDR-consider attitudes; FACL-facial appearance concerns; BICP-behavioural intentions towards cosmetic procedures 137 To verify the discriminant validity , the construct correlations matrix was computed, and AVE analysis was conducted. The bold diagonal represents the square root of AVE. As shown in Table 16, it could be observed that all construct correlations (off diagonal) are lower than the values on the diagonal. Hence, the discriminant validity was verified. Table 16 - Construct Correlations and AVE Analysis SMI PI FI INTR APP SS MTR INTRP SOCL CONS FACL RLG BICP SMI 0.868 PI 0.384 0.782 FI 0.379 0.608 0.789 INTR 0.525 0.261 0.275 0.740 APP 0.483 0.298 0.340 0.719 0.724 SS 0.564 0.320 0.372 0.603 0.620 0.674 MTR 0.306 0.240 0.209 0.400 0.265 0.361 0.782 INTR 0.225 0.026 -0.003 0.202 0.087 0.179 0.161 0.843 SOC 0.168 0.183 0.151 0.308 0.189 0.210 0.236 0.578 0.793 CONS 0.223 0.112 0.045 0.215 0.163 0.134 0.194 0.679 0.713 0.847 FACL 0.143 0.322 0.251 0.208 0.157 0.088 0.216 -0.046 0.257 0.071 0.805 RLG 0.020 -0.066 -0.039 0.007 -0.060 0.028 0.013 -0.094 -0.058 -0.112 -0.091 0.754 BICP -0.283 -0.094 -0.027 -0.351 -0.236 -0.183 -0.104 -0.531 -0.575 -0.503 -0.079 -0.091 0.679 SMI-social media influence; PI-peer influence; FI-family influence; INTR-internalization of appearance ideals; APP-appearance comparison; SSself-surveillance; MTRmaterialism; INTR-interpersonal attitudes; SOC-social attitudes; CONS-consider attitudes; FACL-facial appearance concerns; RLG-religiosity; BICP-behavioural intentions towards cosmetic procedures 5.5. Second Order Model CFA The Confirmatory Factor Analysis (CFA) was also performed considering the second order construct attitude towards CS (ATTCS) (Hair et al., 2010). Therefore, a second order construct was proposed in order to represent the ATTCS construct (which includes Interpersonal, Social and Consider). Each of them is indicated by three measurement items. The correlations between the first-order factors were shown to be relatively high (more than 0.70), providing statistical evidence for a second-order model (Garver & Mentzer, 1999). This showed that respondents probably view the phenomenon at the second order level. In other words, the findings suggest that the acceptance of CS could be used for assessing internal and external motivations for undergoing CS. The validity and reliability of the model with the second order factors was also assessed. The measurement model with second order factors is next presented in Figure 14. 138 Figure 14 - Measurement Model with Second Order Factors 139 The second order model revealed similar overall fit to the first order model, with a slight improvement. As can be seen in Table 17, The metrics fit of the model with the second order constructs are: χ2/df=1.159; GFI =0.934; AGFI=0.915; NFI=0.935; TLI = 0.988; CFI= 0.990; RMR=0.045; and RMSEA =0.017. Table 17 - Summary of Goodness-of-fit Measures Measures X2 /df GFI AGFI NFI TLI CFI RMR RMSEA CFA 2nd order 1.159 0.934 0.915 0.935 0.988 0.990 0.045 0.017 CFA 1st order 1.367 0.924 0.903 0.925 0.974 0.978 0.044 0.026 Threshold < 3 (ρ<.05) > 0.90 > 0.90 > 0.90 > 0.95 > 0.90 < 0.09 < 0.08 X2–Chi-square; GFI–Goodness of Fit Index; AGFI–Adjusted Goodness of Fit; NFI–Normed Fit Index; TLI–Tucker Lewis Index; CFI–Comparative Fit Index; RMR–Root Mean Square Residual; RMSEA–Root Mean Square Error of Approximation Table 18 provides information regarding construct validity with values for construct reliability (CR) and average variance extracted (AVE) for the constructs. As can be depicted, both metrics are above the thresholds referred, namely, AVE in the range [0.500-0.745] and CR in the range [0.704-0.921], which confirms the convergent validity. Table 18 - Construct Reliability and AVE with Second Order Constructs Constructs CR AVE SMI 0.921 0.745 PI 0.813 0.612 FI 0.820 0.623 INTRN 0.780 0.548 APP 0.769 0.528 SS 0.704 0.450 MTRLSM 0.776 0.538 RLG 0.791 0.568 ATTCS 0.889 0.731 FACL 0.828 0.617 BICP 0.717 0.500 SMI-social media influence; PI-peer influence; FI-family influence; INTRN-internalization of appearance ideals; APPappearance comparison; SS-self-surveillance; MTRLSM-materialism; RLG-religiosity; ATTCS attitudes towards cosmetic surgery; FACL-facial appearance concerns; BICP-behavioural intentions towards cosmetic procedures