How Do Instagram Posts Affect Young Females’ Attitudes
Towards Cosmetic Surgery: The Role of Appearance Self-esteem
Huilan Xu (11579544)
Supervisor: Susanne Baumgartner
Graduate School of Communication
Master’s programme Communication Science
Word count: 7480
Abstract
Although increasing cosmetic surgery content appeared on Instagram, little is known about
whether these posts have temporary effects on people’s attitude towards cosmetic surgery and whether the portrayals and the Instagrammers exert some difference. Due to the difference in
self-evaluation and appearance satisfaction, these effects of Instagram posts on body
image-related thoughts might also differ according to people’s 3appearance self-esteem. The
aim of the current study was to examine the relationships between cosmetic surgery
portrayals, the identity of Instagrammers and people’s attitude towards cosmetic surgery and compare the difference between people who have high appearance self-esteem and low
appearance self-esteem. I designed a 2 (text: positive vs negative) x 2 (source: doctor vs
patient) between subject design with an additional control group. The final sample consisted
of 158 female participants (aged 18-30). The results showed that no significant effect of a
positive versus a negative portrayal, nor an effect of the source of the post was found on
people’s basic beliefs and consideration on doing cosmetic surgery. The moderating effect of appearance self-esteem was also insignificant. Reasons for why the expected priming effect
did not occur were discussed.
Keywords: Instagram, Body-image, Cosmetic surgery, Portrayal, Source credibility, Appearance self-esteem, Attitudes
Introduction
Social media (e.g., Twitter, Instagram) in recent years has provided people with increasing
information on cosmetic surgery and has changed people’s attitude towards it. The demand for cosmetic surgery has drastically increased in the past few years. According to the
American Society of Aesthetic Plastic Surgery (ASAPS), in the United States, there was a 9%
overall increase in surgical and nonsurgical procedures during the year 2016 (ASAPS, 2016).
Ozan and Ufuk (2017), Nichola and Phillippa (2018), Wen, Chia and Hao (2017) all suggest
that social network sites can promote the acceptance of using surgical methods to improve
appearance.
Instagram is an image-based social media platform where around 80 million photos are
uploaded every day. Selfies and enhanced photos are very popular in this platform. An
increasing number of Instagram posts containing content related to cosmetic surgery are
being posted by organisations such as ASAPS, plastic surgeons and others (Dorfman, Vaca,
Mahmood, Fine & Schierle, 2017). These posts can affect people’s attitudes. The extent of the
effects might differ by the source of a post. Aside from professional sources, patients who
have had cosmetic surgery might also put information on Instagram. This could be
particularly influential to others as they have experienced it themselves. In this study, the
influences of professionals compared to previous patients will be compared.
As well as the identity of the Instagrammers, the negative and positive impacts must also
be considered. Wen, Chia, and Hao (2015) analysed cosmetic surgery videos on YouTube and
found that most of the videos only described the benefits of cosmetic surgery; only a few
cosmetic surgery is frequently posted on Instagram (Dorfman et al., 2017). The way that
messages are delivered lead to different thoughts being primed. For example, emphasizing
the benefits and advantages may help persuade people towards cosmetic surgery. It is
worthwhile measuring the effects presenting cosmetic surgery in different ways on Instagram.
When investigating the effects of social media content, it is also important to take
people’s individual differences into account. For instance, people have different levels of appearance self-esteem. Appearance self-esteem refers to a person’s level of satisfaction and
attitude towards their own appearance (Stice & Shaw, 2002). Improving their own body
image was found to be a strong motive for adolescents to embrace cosmetic surgery.
Meanwhile, thin ideal internalization led to more acceptance to cosmetic surgery (Lunde,
2013). It is reasonable to assume that people with low appearance self-esteem may be more
likely to be influenced by the vast amount of positive information regarding cosmetic surgery.
Therefore, the main objective of the present study is to investigate the effects of the
sources of information and the portrayal of cosmetic surgery on Instagram, as well as the role
of the differences in individuals. It can shed some light on research related to the dynamic
relationship between image-focused social media and people’s attitude towards cosmetic
surgery. Relevant organisations such as ASAPS can also explore a more effective way to
communicate educational information on social media. Meanwhile, clinics can better devise
their communication and online marketing strategies.
Theory background The Effects of Using Social Media
young adults, and this may lead to thoughts about improving their physical appearance (de
Vries, Peter & Nikken, 2014). They can be either directly affected by being dissatisfied with
their own appearance or they might receive negative judgement and comments from others in
social media. They might also look at others and the compliments that they receive. Under
the pressures of getting more positive feedbacks, , they may be more likely to change their
appearance in order to become more attractive. Thus, they might develop positive attitudes
toward cosmetic surgery.
Previous studies found some correlation between exposure to cosmetic surgery content
in social media and people’s attitudes towards cosmetic surgery (Markey & Markey, 2010; Tiggemann & Miller, 2010). Swami (2009) showed that body appreciation, media influence
and body mass index (BMI) were significant predictors that lead to the consideration of
cosmetic surgery among female undergraduates. De Vries, Peter, and Nikken (2014) indicated
that more frequent use of SNS can increase a person’s desire to undergo cosmetic surgery.
Twitter use was also found to be related to increased acceptance of cosmetic surgery among
people who watch cosmetic surgery programmes on TV (Fogel & King, 2014). Similarly,
Abbas and Karadavut (2017) compared people who have had surgical procedures and people
who had never wanted any cosmetic surgery. They demonstrated the important role of social
media usage in the increasing acceptance in society of surgical procedures that enhance a
person’s appearance.
Although the existing research has established an association between social media use
and people’s attitudes regarding cosmetic surgery, there are still several areas in the literature to be researched. Surveys and content analysis were mainly used to investigate the correlation
between media use and sexual behaviour, body appreciation, consideration of cosmetic
surgery and appearance investment (Swami, 2009; Slevec & Tiggemann, 2010; Dorfman et
al., 2017; Wen et al., 2015). It cannot provide evidence for a causal and direct effect.
Additionally, despite the increasing cosmetic surgery-related content on Instagram, no
study yet has focused on the specific positive and negative effects of Instagram posts or the
role of the Instagrammers. Sternheimer (2013) concluded that although the representation of
alcohol, smoke, drugs, fitness in media has been thoroughly discussed, the research
conducted on specific cosmetic surgery messages and their sources in social media is still
scarce.
Female Young People as a Particularly Vulnerable Target Group
ISAPS (2015) reported that in America, more than 12 million young people under 34 years
old had cosmetic surgery. When people were young, their attitudes could be easily affected by
others and the standards of beauty in society (Myers & Crowther, 2009). Among the people
who had cosmetic surgery in 2017, there were eight times as many women compared to men
(ISAPS, 2017). Swami, Arteche, et al. (2008) pointed out that women are much more willing
than men to undergo cosmetic procedures. Women reportedly used SNS more and were more
likely to have appearance enhancement procedures (de Vries, Peter & Nikken (2014). Based
on empirical statistics and research, it may be thought that young women are more sensitive
and susceptible to cosmetic surgery related content. For this reason, young female aged
between 18-30 is the target population in this study.
Therefore, in order to further existing research, the research question in the current study
Instagrammers affect young females’ attitudes towards cosmetic surgery? Also, is this relationship moderated by a person’s appearance self-esteem?
Priming Theory and the Role of Portrayals
Immediate effects on someone’s body image can be created through media exposure
(Birkeland, Thompson, Herbozo, Roehrig, Cafri &van den Berg, 2003). Priming theory
indicates that audience’s related thoughts can be stimulated by media images (Berkowitz & Powers, 1979). The ideas involve nodes in the associative network of a person’s memory.
When people are exposed to media content, the related nodes are activated and may serve as
a guideline to process or judge information (Pan & Kosicki, 1997). Moreover, people tend to
interpret a new message with recent information and this happens subconsciously (Valenzuela,
2009; Valenzuela, 2009). Specifically speaking, recent information people had obtained
would be immediately recalled. For instance, if people are exposed to some positive
comments about cosmetic surgery on media, the related ideas about cosmetic surgery in their
memory would come to mind. Also, people tend to evaluate cosmetic surgery more positively
because they would probably describe this topic based on the positive content they just saw.
Through exposure to the portrayals of cosmetic surgery on Instagram, people’s related thoughts might be primed and their thoughts of having cosmetic surgery might be changed
accordingly. When cosmetic surgery is portrayed as successful and positive it may promote
the desire or acceptance for cosmetic surgery; however, when cosmetic surgery is portrayed
as risky and negative it can lead to fear in surgical appearance investment. For example, it has
been shown that TV shows which portrayed plastic surgery in a positive way made people
The positive images related to cosmetic surgery on Instagram could enhance the likelihood of
a short-term desire to have cosmetic surgery (Abbas & Karadavut, 2017). Brooks (2004)
stated that expressions of satisfaction from a patient who has done cosmetic surgery led to
positive views on cosmetic surgery.
Cosmetic surgery can be portrayed in different ways through Instagram posts using
cues in photos as well as the message in the texts. In previous research, the contribution of
photos was emphasized, whilst the role of the captions was neglected. However, the words
are important as the way that cosmetic surgery is described can deliver different messages
and affect people’s attitude towards cosmetic surgery differently (Bandura, 2009; De Graaf, 2013). The same picture can have different meanings when accompanied by negative or
positive textual information. For instance, a picture that presents successful cosmetic surgery
may be captioned with text promoting cosmetic surgery or educational content such as the
risks behind it. Aside from the hidden cues in the images, people can obtain more direct
information from texts. Whether these messages on an image-centred social media platform
have a significant effect is worth examining. Thus, it is reasonable to suggest that whether the
messages in texts are positively or negatively presented can also affect perceived risks or
benefits of plastic surgical procedures and change people’s attitudes towards cosmetic surgery. Therefore, the first hypothesis is:
H1: Being exposed to an Instagram post containing a positive message about cosmetic
surgery will lead to more positive attitudes towards cosmetic surgery compared to being
exposed to a post with a negative message or no cosmetic surgery content.
providing negative messages, including the consequences, about alcohol drinking is an
effective method of reducing alcohol use. She found presenting negative consequences
increased negative beliefs but presenting the positives of alcohol consumption did not create
more positive beliefs (De Graaf, 2013). This phenomenon was explained by the negativity
bias theory, which states that the influence of negative messages is generally more powerful
than the influence of positive information (Baumeister et al., 2001; Rozin & Royzman, 2001).
In this study, whether mentioning negative information about cosmetic surgery is able to
exert stronger effect on discouraging people to accept cosmetic surgery compared to the
effect of a positive message that encourages people to accept cosmetic surgery will be
investigated. Thus, the second hypothesis is:
H2: Being exposed to an Instagram post containing a negative message about cosmetic
surgery produces a stronger influence on people’s attitudes towards cosmetic surgery compared to being exposed to an Instagram post containing a positive message.
Source Credibility
The message source refers to the person who conveyed the information to the audience.
Audiences can perceive different levels of prestige, glamour, expertise and trust according to
the characters who carry the messages; this affects how they process the messages (Wen et al.,
2015). In online persuasive communication, experts and previous consumers were found as
the two most common message sources (Wen et al., 2015). Having an expert source means
the messages come from someone whose opinions or facts have been verified with evidence.
This can enhance people’s trust and acceptance of the information ((Biswas, Biswas, & Das, 2006). Messages presented by people who have used the product come from a consumer
source; their testimonials or the level of satisfaction also matter in persuasive communication
(Stafford, Stafford, & Day, 2002).
As misinformation and rumours spread widely in social media, users become more
careful about the things that they read online (Castillo, Mendoza & Poblete, 2011). The
credibility of information has become a great determinant in communicating with an audience
and persuading them (Amelina & Zhu, 2016). According to the Elaboration Likelihood
Model, both central routes and peripheral routes should not be neglected while delivering a
message and persuading people. The central route emphasises that people consider the
message content itself. On the other hand, the peripheral route indicates that people pay more
attention to other cues, such as the perceived expertise of a source (Pornpitakpan, 2004). In a
study by Amelina and Zhu (2016), the effects of peripheral cues in Instagram advertisements
were examined. It was discovered that the expertise and trustworthiness of endorsers were
significant factors in influencing the attractiveness of a product. Moreover, trustworthiness
was found to play a critical role in affecting people’s attitudes towards the brand, which highlighted its significance in delivering persuasive messages and social trust (Amelina &
Zhu, 2016). This result emphasizes the role of peripheral cues.
Current research suggests that the credibility of an Instagram post containing cosmetic
surgery content may also be associated with the identity of the Instagrammer. In recent years,
most plastic surgeons reported that they have used social networking sites to convey
messages to their existing or potential customers. For example, they might explain the safety
issues about the surgical procedures. At the same time, many patients were told to share their
adverse effects that could occur (Bechmann & Lomborg, 2012). It showed that professional
sources were used primarily. Other types of sources including patients, as a consumer source,
were also popular and widely used to deliver information about cosmetic surgery (Wen et al.,
2015). Therefore, the communication effect of these predominant sources, the surgeons and
patients, will be compared.
In line with the theories about source credibility, the two main concepts, expertise
influence and trustworthiness, will be applied. Professional plastic surgeons are experts and
the content they communicate should contain a high level of expertise and trustworthiness.
The words of previous patients might also be thought to be quite trustworthy as they express
what they personally experienced and felt themselves. However, their lack of expertise would
make them relatively less credible than the doctors because cosmetic surgery involves a lot of
professional medical knowledge. Evident skills and knowledge are important in convincing
the audience when it concerns a person’s health (Chang et.al 2012). Thus, the third hypothesis is:
H3a: Positive cosmetic surgery posts created by a doctor leads to more positive attitudes
toward cosmetic surgery compared to posts which have been created by previous patients.
H3b: Negative cosmetic surgery posts presented by a doctor leads to more negative
attitudes toward cosmetic surgery compared to negative cosmetic surgery posts from a
patient.
Self-esteem as a Moderator: The Role of Individual Difference
As we know, the media can sometimes affect people’s attitude indirectly. The Differential Susceptibility to media effects model (DSMM) will be applied in this study because it
considers indirect effects caused by disparities from different propositions. Body
dissatisfaction and self-esteem can be a significant factor in the effect of media on people’s
attitude towards cosmetic surgery. People who were not satisfied with their appearance tend
to pay more attention in managing their appearance and were more likely to be sensitive to
content related to body image in the media (Dohnt & Tiggemann, 2006; Cash, 2012). As
cosmetic surgery provided a new way to help people reach the ideal standard of beauty by
modifying their appearance, the dissatisfaction someone has toward their body and low
self-esteem can be associated with more positive attitudes towards cosmetic surgery (Sarwer
&Crerand, 2004).
Meanwhile, priming theory suggests that the media stimulus can temporarily trigger
users’ specific cognitions (de Vries & Peter, 2013). The encountered messages can be interpreted differently by individuals according to their existing knowledge or characteristics.
People who have low self-esteem in their appearance might be more vulnerable while being
exposed to more objectifying content (e.g., people’s body parts) in media. This is because people with low appearance self-esteem may have stronger cognition of appearance
comparison (Ward, 2016; Tiggemann & Zaccardo, 2015). Besides, the cognitive empathy
may work during this exposure. When people in the media share more common
characteristics with the audience, the audience would be more likely to understand the
perspectives shown in the media (Rogers, Dziobek, Hassenstab, Wolf & Convit, 2007). For
instance, if people see a girl who have had trouble with appearance the same as them, but had
improved her appearance through surgical methods, then it is more likely that they may do
H4: Appearance self-esteem moderates the effects of cosmetic survey posts. People with
high appearance self-esteem are less affected by portrayals of cosmetic surgery in media than
those with less appearance self-esteem. This is regardless of whether the information is
positive and negative.
Method Sample and Sampling Procedure
To test the hypotheses in the current study, an online experiment was designed and created in
Qualtrics. The target population were females aged from 18 to 25 years. 150 females were
supposed to be recruited in the study. Finally, there were 228 participants in total that took
part in the online experiment. Of those, 70 participants (30.7%) were removed because of
incomplete data. The final sample consisted of 158 females. The average age of participants
was 23.34 (SD = 2.53) years.
Different ways were used to recruit participants in order to increase the diversity of the
sample. Through online channels, the recruitment invitation was posted on social media
including the Facebook page of the college of University of Amsterdam and the specific
WeChat group (e.g., the group that formed by Chinese students in the Netherlands). For
offline channels, the participants were reached at some places where young people like to go,
such as the campus of universities in the Netherlands, some restaurants and bars. After getting
their agreement and email addresses, they received the link to the online experiment.
Participants were randomly assigned to one of five conditions. There were no
differences between these five groups in terms of age, F (4, 153) =1.22, p = .31 Participants
were from 26 different countries which included among others Britain (8.1%), the
Romania, Italia, Greece. When it comes to the amount of time using Instagram per day, a
mean of 2.37 hours (SD = 1.86) was reported, and no differences were found among these
five groups, F (4) = 1.11, P = .35.
Design
The experiment was a 2 (text: positive vs negative) x 2 (source: doctor vs patient) between
subject design with an additional control group. One factor in the experiment was cosmetic
surgery portrayals on Instagram, which included 2 categories (i.e., positive portrayals versus.
negative portrayals of cosmetic surgery). The other factor was the identity of Instagrammers,
also including two categories (i.e., doctor vs. patient). In the first part of the experiment,
participants were asked to report the information about their age, nationality as well as the
frequency of using Instagram. Then they were shown the stimulus materials, which include
two normal Instagram posts (about travel and pets), one Instagram post about cosmetic
surgery as well as the page of Instagrammer’s information, which presented their personal information in real life. For example, their names, occupations (surgeons vs. students), phone
numbers or locations were shown on the page.
In the four experimental conditions, the pictures were showing the same woman’s face before and after cosmetic surgery (see appendix. A). In the positive text conditions,
participants were shown the picture with a positive statement (encouraging people to try)
cosmetic surgery, while in the negative text condition, participants were shown a negative
statement (mentioning the risks, such as pain, money, time) on cosmetic surgery.
Time-consuming, money-consuming and possible stigma were the main factors that hinder
negative consequences could effectively stimulate their negative thoughts about cosmetic
surgery and weaken their willingness of doing it. Meanwhile, the comment such as “painful”
could increase people’s feeling of fear, which was a critical emotion triggered by media
(Bartsch, Vorderer, Mangold & Viehoff, 2008). In the patient groups, participants were
exposed to the statement by a patient and a patient’s profile page, whereas in the doctor
groups, the statement was posted by a doctor, followed with a doctor’s profile page. After exposure to those pictures, participants were required to fill in the scales that were used to
measure people’s appearance self-esteem and attitude towards cosmetic surgery.
Measurement
Positive versus negative portrayals: The valence of the portrayal was manipulated by
the text underneath the Instagram posts. In the first two conditions, the variable was
operationalized through a patient’s positive comment on cosmetic surgery (“A successful cosmetic surgery! I became so much prettier! Worth trying!”) or negative comment on herself
doing cosmetic surgery (“I became prettier after cosmetic surgery, but I don’t think it is worth it. It was very painful could be risky! Also, it took a long time and a lot of money”). In the third and fourth condition, the texts were the same but presented by a surgeon’s tone. The
screenshots can be found in the appendix.
Instagrammer: The identity of the Instagrammer was operationalized by presenting
personal information about the Instagrammer who posted the post about cosmetic surgery.
The effect of surgeon and patient was compared in this study. Two characteristics were
created for the experiment- doctor Robinson and a girl named Daen, who has undergone
two groups a doctor’s photo was shown. Additionally, their profile pages were also presented. On the patient’s profile page, the location and age information were presented (Seoul girl,
1990). On the surgeon’s profile page, the location and contact information were stated
(Beverly Hills, phone number: 02-310-2315). After the exposure, participants were asked the
question “who posted the post about cosmetic surgery” to test if they recognized the identity of the Instagrammers.
Attitudes towards cosmetic surgery. This was measured with 16 items that were from
King (2005)’s Scale of Acceptance of Cosmetic Surgery. In addition to the original items, two items that measure attitudes on other people doing cosmetic surgery were added to the
original scales. An example item from the final scale is “It makes sense to have minor
cosmetic surgery rather than spending years feeling bad about the way you look”. The
response options ranged from 0 (strongly disagree) to 7 (strongly agree). These items mainly
explain the attitudes towards cosmetic surgery in two domains: basic beliefs on cosmetic
surgery (e.g., “Cosmetic surgery is a good thing because it can help people feel better about themselves”) and consideration on doing cosmetic surgery themselves (e.g., “I would think about having cosmetic surgery in order to keep looking young.”).
A factor analysis revealed that the KMO measure of sampling adequacy was .91, and
Bartlett’s test of sphericity was also significant (p < .001). There were two factors with an Eigenvalue bigger than 1. After direct Oblimin rotation, the items were divided to two
categories, 7 items are explaining factor 1, while the other 9 items are explaining factor 2. So
the two factors were named: factor 1- “basic beliefs on cosmetic surgery”, factor 2-
can be seen in the appendix. These two factors were used as separate dependent variables in
the following analysis, with two mean indexes built out of the items respectively. The
response options ranged from 0 (strongly disagree) to 7 (strongly agree). Therefore, mean
scores could range between 0 and 7, with higher scores indicating that the participant has
more positive beliefs on cosmetic surgery or more likelihood to consider cosmetic surgery.
For factor 1, the results of the reliability test showed that Cronbach’s alpha was .82 (M = 4.46, SD = .94). Similarly, for the 9 items for people’s consideration on doing cosmetic surgery themselves, the Cronbach’s alpha was .95 (M = 3.37, SD = 1.55).
Trait appearance self-esteem. To test if appearance self-esteem would be a moderator
affecting the media impact, items for the scale appearance self-esteem were selected from
Heatherton & Polivy (1991)’ s Self-Esteem Scale. The original scale assesses self-esteem from five dimensions: academic, performance, social, appearance, and general self-esteem.
The six items that measure appearance self-esteem were selected and used in the current
research. In this experiment, the facial part would be focused and presented in the posts. To
make the items better serve my aim, some words were changed in original items, for example,
“weight” was changed to “face”. An example item is “I am satisfied with my face”. The complete scales can be seen in the appendix.
To test if the six items were forming a reliable scale to measure appearance self-esteem,
a factor analysis as well as a reliability test were conducted. The results showed that the
KMO measure of sampling adequacy was .88, and Bartlett’s test of sphericity was also significant (p < .001). Meanwhile, there was only one factor with an Eigenvalue bigger than 1,
items. The response options ranged from 0 (strongly disagree) to 7 (strongly agree). Thus, the
scores for appearance self-esteem also ranged between 0 and 7, with higher scores indicating
participant showed a high level of appearance self-esteem. The factor loadings for the items
ranged from .64 to .84. The result of reliability test showed that Cronbach’s alpha was .90 (M
= 4.50, SD = 1.14).
Results Manipulation check
To check if participants recognized the identity of the Instagrammer, a cross-tab analysis was
conducted on their answer to the question:” who posted the post about cosmetic surgery?” It shows that 21 people (13.29%) in total failed to recognize the identity of the Instagrammers,
while 86.71% of participants successfully passed this manipulation check. People in the
patient condition somewhat better (84.75%) remembered the identity of Instagrammer than
participants in the doctor condition (81.54%).
In order to check whether the participants evaluated the text portrayal condition as
positive portrayal or negative portrayal, an independent t-test was conducted with portrayals
conditions (positive text vs. negative text) as independent variable, and the evaluation on the
valence of the text (scale of 1 being “extremely positive” and 7 being “extremely negative”) as dependent variable. It turned out that the score on the evaluation for text portrayal was
significantly more positive in the positive text condition (M = 3.30, SD = 1.29) compared to
the negative text condition (M = 4.37, SD = 1.56), t (120) = -4.12, p < 0.001. It means that
participants perceived the positive Instagram post about cosmetic surgery as significantly
more positive than the negative post. This indicates that the manipulation for the valence of
Hypotheses Testing
To check H1 that being exposed to an Instagram post containing a positive message
about cosmetic surgery will be associated with more positive attitudes about cosmetic surgery
compared to being exposed to the post with a negative message and no cosmetic surgery
content, two one-way ANOVA were conducted, with the portrayal of Instagram posts
(positive vs. negative vs. control group) as independent variable, and the basic beliefs on
cosmetic surgery as well as considerations on doing cosmetic surgery as dependent variables.
A non-significant effect of portrayal on basic beliefs was found F (2,155) = .06, p =.94. The
statistics showed that participants in the positive condition (M = 4.47, SD = .88), scored
slightly lower on the basic beliefs on cosmetic surgery than participants in the negative text
condition (M = 4.48, SD = .94), but higher than participants that were in control condition (M
= 4.41, SD = 1.07). The score in the negative condition was even higher than in control
condition. But these differences were not significant.
For the other dependent variable- consideration on doing cosmetic surgery, the effect of
portrayal was also not significant F (2,155) =.41, p = .67. The statistics showed that
participants in the negative condition (M = 3.45, SD = 1.50), scored higher on the
consideration on doing cosmetic surgery than participants that were exposed to the negative
condition (M = 3.41, SD = 1.58) and participants that were in the control condition (M = 3.17,
SD = 1.63). The difference was not statistically significant as well, which means these results did not support H1.
To check H2 which stated that a negative portrayal can exert a stronger effect on
was conducted, with portrayal (positive vs. control group; negative vs. control group) as
independent variable, and basic beliefs about cosmetic surgery as well as consideration on
cosmetic surgery as dependent variables. A non-significant effect of portrayal on basic beliefs
was found between the positive condition (M = 4.47, SD = .88) and the control condition (M
= 4.41, SD = 1.07), t (92) = .78, as well as the negative condition (M = 4.48, SD = .94) and
the control condition (M = 4.41, SD = 1.07), t (96) = .32, p =.75. The Cohen’s d for
comparing the positive condition and the control condition was .06, while for comparing the
negative condition and the control condition was .07. This indicates that in contrast to what
was expected in H2, the negative text had no stronger effect on beliefs.
The effect of portrayal on consideration on doing cosmetic surgery was also found
insignificant between the positive condition (M = 3.41, SD = 1.58) and the control condition
(M = 3.17, SD = 1.63), t (92) = .47, p = .47 , as well as between the negative condition (M =
3.45, SD = 1.50) and the control condition (M = 3.16, SD = 1.63), t (96) = .88, p = .38 The
Cohen’s d in comparing the positive condition and the control condition was .15, while in comparing the negative condition and the control condition was .18. The significant effect of
the negative/positive texts were not found on the two dependent variables. Thus, the
hypothesis that suggested negative texts have a stronger effect than positive texts should be
rejected.
H3 posed that in the positive and negative conditions, the post presented by a
professional (i.e., doctors) will have a stronger effect on people’s attitudes toward cosmetic surgery compared to being exposed to the cosmetic surgery post which is presented by a
patient) and text portrayals (positive vs. negative) as independent variables and basic beliefs
and consideration on doing cosmetic surgery as dependent variables respectively. As shown
already for H1, the main effect of positive vs negative portrayals was not significant. In this
two-way ANOVA, the results showed that the main effect of Instagrammers on basic beliefs
was also not significant F (1,153) = 2.22, p = .14). Moreover, an insignificant interaction
effect between Instagrammer and text portrayals on basic beliefs was found, F (1, 153) = 1.14,
p = .29.
Similarly, the main effect of Instagrammers was found insignificant on people’s
consideration of doing cosmetic surgery F (1, 153) = .87. The interaction effect between
Instagrammers and text portrayals was not significant as well, F (1, 153) = .02, p = .88. Thus,
H3a and H3b should be rejected.
To test H4 which posed that appearance self-esteem could moderate the effect of the
valence of the portrayals, another two-way ANOVA was conducted, with portrayals and
appearance self-esteem as independent variables and basic beliefs and consideration on doing
cosmetic surgery as dependent variables. In order to compare the effect of low and high
appearance self-esteem, participants were divided into a low appearance self-esteem group
versus a high self-esteem group by means of a median split (Median = 4.58). Participants
who scored lower than 4.58 on appearance self-esteem were assigned to the low appearance
self-esteem group while participants whose appearance self-esteem were reported 4.58 and
higher were assigned to the high appearance self-esteem group. The low appearance
self-esteem group consisted of 79 people (M = 3.58, SD = .81), and the high appearance
The outcome showed that the main effect of portrayals was not significant on people’s
basic beliefs, which was the same as the outcome of H1 as discussed above. The main effect
of self-esteem was insignificant as well, F (2,152) = .01, p = .91. The interaction effect of
portrayals and self-esteem was also found not significant F (2, 152) = 1.28, p = .28
For the dependent variable- consideration on doing cosmetic surgery, the main effect of
portrayals was also not found, as we mentioned in H1, while the main effect of self-esteem
was found statistically significant, F (1,152) = 6.87, p = .01. However, the interaction effect
between self-esteem and portrayals was not significant, F (2,152) = .11, p = .90. Since the
moderating effect was not found, the H4 was also not supported.
Conclusion and Discussion
To summarise, the research indicates that the valence of the portrayal of cosmetic surgery
posts on Instagram as well as the identity of the Instagrammer did not lead to an influence on
people’s basic beliefs and considerations on having cosmetic surgery. One-time exposure to cosmetic surgery content on Instagram might not be sufficient to change their attitude. The
short-term priming effect might not occur in a situation where the stimulus was not
significant enough. As opposed to being affected directly by the post, it is more likely that
cosmetic surgery posts led to previous thoughts relating to this topic (Hermans, Houwer &
Eelen, 2008). The target population in this study was adults, whose attitude towards cosmetic
surgery might already be stable, and they are able to critically reflect on the media content
that they were exposed to. In this respect, their fundamental beliefs about cosmetic surgery
could not be easily changed by media content, especially in a short period of time (Prislin,
The portrayal of cosmetic surgery
The non-significant findings in this study can be partly explained by cultivation theory and
repetitive priming. Cosmetic surgery has existed for decades. Knowledge and information
about cosmetic surgery has spread widely on different platforms, such as TV, newspaper and
social media including YouTube (Markey & Markey, 2012). The advantages and
disadvantages of having cosmetic surgery have also been discussed widely in person among
friends and family.
Cultivation theory states that cumulative exposure to media content tends to make
people believe something in the way that it is portrayed in the media (Riddle, 2009). Thus,
through previous exposure to certain views relating to cosmetic surgery, people might already
have a fixed understanding or attitude towards it. Repetitive priming indicates that when
people have an implicit memory about something, there would be an impact of the implicit
memory that prior to a new stimulus (Brickman & Stern, 2009). Therefore, these two theories
both suggest that through repetitive exposure to a stimulus, people might form a relatively
stable attitude. It is likely that participants in this study already had attitudes about the topic
which cannot be changed within a short time. Most adults might already have sufficient
information and a mature understanding of this topic to possess their own views on it.
Therefore, in regard to those who had balanced attitudes on cosmetic surgery, the information
we provided in this study might not be sufficient enough for them to challenge existing
beliefs.
In addition, there was also no difference between the effect of positive and negative
possibility that the difference between the positive and negative post was not distinct enough.
Another explanation for why their thoughts might not have been affected by the portrayal of
cosmetic surgery could be due to the way how the messages were processed. According to
theories on information processing, elements of the message structure and content can
influence how effectively the messages are encoded, stored and retrieved (Lang, 2006).
Instagram is an image-based social media application but a small and less significant may be
written underneath the picture; most people are aware that the main function and feature of
Instagram is to show the pictures. Thus, it is reasonable that people tend to focus on the
photos while on Instagram. The messages presented in the text can sometimes be easily
ignored. In this study, the pictures of cosmetic surgery in each situation were the same and
portrayed in a positive way, which may have caused a strong impression in some participants
that the outcome of cosmetic surgery is positive.
Additionally, even in the negative portrayal, the first part of the text gave a positive
comment on the outcome of the cosmetic surgery. This may have weakened the negative
portrayal and the effects of the negatives mentioned. Therefore, due to the particular structure
and content aspects of the Instagram post in this study, some participants might not have paid
much attention to the positive or negatives exhibited in the text accompanying the pictures.
This could be a reason as to why the participants were not affected in the way that was
predicted.
Source Credibility
The identity of Instagrammers was also found to be insignificant in affecting people’s attitudes towards cosmetic surgery. As media has increasingly become an information source,
source credibility has become very important when people obtain information online. It
indicates the quality of the message and how much it will be believed. How people gather
information and how they assess source credibility is an important question to be investigated
(Westerman, Spence & Van Der Heide, 2012; Westerman, Spence & Van Der Heide, 2014).
In this study, I compared the effects of the same post once posted by a surgeon and once
posted by a patient. However, no significant difference was found in the effects of these
different sources, meaning that the credibility of patients and doctors might have been similar
in the experiment. The role of expertise of plastic surgeons cannot be denied. A person’s point of view on medical issues can easily be manipulated by the knowledge of a professional
because their information is reliable and trusted (Chanthika, 2004; Birnbaum & Stegner, 1979;
Lanseng & Andreassen, 2007). So, when talking about how cosmetic surgery could have risks
or benefits, the information from an expert can be more powerful.
On the other hand, the credibility of a patient can also be high. We can see from the
results that in the negative condition, although the effect was not significant, it seems that
people in the patient condition scored lower in consideration on doing cosmetic surgery
compared to people in doctor condition. Trust is also a critical determinant in accepting
information because it affects the level of perceived usefulness and their expectations (Pavlou,
2003). When it comes to the health issues and surgical method, the words from a patient who
just experienced a specific procedure may be considered very reliable (Lau, Siek,
Fernandez-Luque, Tange, Chhanabhai, Li, Elkin, Arjabi, Walczowski, Ang& Eysenbach,
2011). When negative feelings such as pain are mentioned, feelings of fear may become
differences in the effects of posts from the two different sources.
Furthermore, we cannot ignore the fact that nowadays the profiles of people online are
not always real (Zhang, Sun, Zhu &Fang, 2010). This could also be a reason why the effect of
a different source did not emerge. As an increasing number of unlicensed surgeons and false
information has appeared online, most people become more cautious and critical to online
information. Sometimes they might doubt the identity and content that some Instagrammers
present. Instagrammers could lie to gain some interests; it could be advertising for a specific
clinic or self-marketing (Mowafa, 2013; Dorfman, Vaca, Mahmood, Fine & Schierle, 2018).
Both surgeons and patients could exaggerate the outcomes of cosmetic surgery. The
complexity and lack of authenticity on some parts of the internet could weaken the effects of
the identity of Instagrammers.
Appearance Self-esteem
The moderating effect of self-esteem was not seen in this study. However, the results revealed
the predicting effect that self-esteem has when people consider cosmetic surgery. When
presented positive and negative information, people with low self-esteem showed more
willingness in having cosmetic surgery. This means people with low self-esteem may have
stronger intentions to have cosmetic surgery in general. Low self-esteem reflects the fact that
there is a substantial difference in how people would like to be and how they actually are
(Figueroa, 2001). Individuals who are dissatisfied with themselves become sensitive to
appearance and demand to pursue an ideal self. One way to achieve this might be through
cosmetic surgery (Figueroa, 2001).
This study used an experiment to examine if exposure to an Instagram post can affect
people’s attitudes towards cosmetic surgery. However, there are still some limitations in the experiment. Firstly, there is only one post with only one picture as stimulus in the experiment.
To increase the ecological validity of the results, I used two irrelevant posts in addition to the
manipulated one. Participants should not realise the purpose of the study, but the effect of the
stimulus materials might have been too weak to trigger a change in attitudes. For future
studies, more Instagram posts containing different cosmetic surgery content can be chosen
and presented to the participants. Attention needs to be paid to the other existing messages
about cosmetic surgery on Instagram; they should be included in the experiment. These might
include the introduction to a specific kind of cosmetic surgery; information on discounted
cosmetic surgery or a self-marketing post from a plastic surgeon.
Secondly, as it was mentioned above, the manipulation of portrayals might be
problematic to some extent. In both positive and negative conditions, the portrayal of the
photo about cosmetic surgery was positive, and the text in the negative condition also
included some positive comments. People could be impressed by the positive comments in
the first part of the text and ignore, or even miss, the second part of the text that mentions the
risks. This could weaken the negative portrayal of the text. Future studies should consider
more how to better manipulate portrayals features in each post and keep other variables are
well controlled. For example, the portrayal of the photo can be changed through facial
expressions (e.g., smiling vs. crying); meanwhile, the text could present different moods and
emotions (e.g., happy vs. sad). In addition, the different forms of presentation should be
How it portrays cosmetic surgery and how the effect of it differs from pictures alone or
pictures with texts are also worth studying.
Thirdly, cultural differences were not considered in this study. The pictures only
presented an Asian woman so might not have influence people of other races. Empathy might
be stronger when the audience sees more similarities between people in the media and
themselves (Schultze, Schultze, Zagorscak, Wölfer & Scheithauer, 2015). The standard of
beauty varies in races and cultures. Therefore, cultural differences could be considered.
Cosmetic surgery has become more popular all over the world and there are particular
countries, such as Korea, who have a great acceptance of cosmetic surgery; however, it is still
difficult for a lot of people to accept it due to cultural or religious reasons (Swami,
Chamorro-Premuzic, Bridges & Furnham, 2009). Additionally, preferences on body image
also vary from country to country. For example, western people prefer sexy lips and Asian
people pursue double-fold eyelids. These preferences could affect the impact in different
portrayals of cosmetic surgery.
Fourthly, a qualitative research approach could help to explore the underlying
motivations. For instance, how are people’s feeling after reading the post and what is the
determining factor that changes their attitudes?
Furthermore, there are some sample biases. The sample size was too small, with only
approximately 30 people per experiment group. Moreover, snowball sampling was used in
this study and most of the participants were students from the University of Amsterdam. This
decreased the diversity of the sample. For future studies, more participants should be
applied. The role of individual differences, such as occupation, could also be tested in future
research. A person’s occupation has been found to be very important in affecting their desire for cosmetic surgery (Barone, Cogliandro, Monaca, Tambone & Persichetti, 2015). Role
performance, such as the ability to carry out activities or the need for a job is the very
important part in one’s self-concept (Figueroa, 2001). To look more physically attractive for a job might also lead them to have cosmetic surgery and they may be further persuaded by
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Appendix A. Screenshots for Stimulus Materials Condition 1. Patients * Positive
Condition 2. Patients * Negative
Condition 3 Doctor * Positive
Condition 4. Doctor * Negative
Appendix B. Factor Loadings for Items
Table 1. Pattern Matrix
item factor Basic beliefs Consideration on doing cosmetic surgery It makes sense to have minor cosmetic surgery
rather than spending years feeling bad about the way you look
.536
Cosmetic surgery is a good thing because it can help people feel better about themselves.
.730
Cosmetic surgery can be a big benefit to people's self-image.
.631
I approve of people undergoing cosmetic surgery to increase their self-esteem.
.675
I think people should do whatever they want, in order to have a good-looking appearance.
.486
People who are very unhappy with their physical appearance should consider cosmetic surgery as one option.
.539
If cosmetic surgery can make someone happier with the way they look, then they should try it.
.579
In the future, I could end up having some kind of cosmetic surgery.
.773
I have sometimes thought about having cosmetic surgery.
.756
If I knew there would be no negative side effects or pain, I would like to try cosmetic surgery.
I would seriously consider having cosmetic surgery if my partner thought it was a good idea.
.854
I would seriously consider having cosmetic surgery if I thought my partner would find me more attractive.
.839
I would think about having cosmetic surgery in order to keep looking young.
.679
If it would benefit my career, I would think about having plastic surgery.
.838
If a simple cosmetic surgery procedure would make me more attractive to others, I would think about trying it.
.895
If I could have a surgical procedure done for free, I would consider trying cosmetic surgery.
.831
Appendix C. Scales of Appearance Self-esteem
(1 “totally disagree” to 7 “totally agree”).
I feel satisfied with the way my body looks right now. I feel that others respect and admire me.
I am satisfied with my face. I feel good about myself.
I am pleased with my appearance right now. I feel myself attractive.
