Reducing eating disorder risk factors: A pilot effectiveness trial of a train-the-trainer approach to dissemination and implementation

Adaptation and implementation of body project as a universal body image program in Mexico and Latin America

The Body Project (BP) intervention for body image issues is supported by extensive efficacy and effectiveness research, most of which has been conducted in the United States. The BP uses cognitive dissonance to help participants critique the ideal appearance through written, verbal, and behavioral exercises. This reduces the internalization of the appearance ideal, which in turn decreases body dissatisfaction symptoms and, in some individuals, the onset of eating disorders. To broadly implement this program in Mexico and Latin America, Comenzar de Nuevo (CdN), a non-profit organization for eating disorder treatment, partnered with the Body Project Collaborative in 2014. Together, they created a training and implementation infrastructure. This paper explores the adaptation of BP and its implementation in Mexico and Latin America. We used sustainable business, marketing, and educational models to fulfill CdN's mission to reduce eating disorder risk factors, including weight stigma, in the Latin American region. By integrating strategies to combat weight stigma within our program delivery, we strive to contribute to a more inclusive and supportive environment. We trained master trainers, regular trainers, and/or group facilitators from Argentina, Bolivia, Colombia, Costa Rica, Chile, Dominican Republic, El Salvador, Guatemala, Mexico, Panama, and Spain; and implemented the BP in 15 public schools supported by sponsorship programs. This paper provides crucial lessons learned, future directions, and implications for dissemination and implementation efforts in this region of the world.

Prevention and early intervention in eating disorders: findings from a rapid review

BACKGROUND

Eating disorders (EDs) are complex psychological disorders, with low rates of detection and early intervention. They can lead to significant mental and physical health complications, especially if intervention is delayed. Given high rates of morbidity and mortality, low treatment uptake, and significant rates of relapse, it is important to examine prevention, early intervention, and early recognition initiatives. The aim of this review is to identify and evaluate literature on preventative and early intervention programs in EDs.

METHODS

This paper is one of a series of Rapid Reviews, designed to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded, and released by the Australian Government. To provide a current and rigorous review, peer-reviewed articles between 2009 and 2021 published in English were searched across three databases: ScienceDirect, PubMed and Ovid/Medline. Priority was given to high-level evidence including meta-analyses, systematic reviews, Randomised Control Trials, and large population studies. Findings from selected studies pertaining to prevention and early intervention in EDs were evaluated and are presented in this review.

RESULTS

In total, 130 studies were identified in the current review, 72% relating to prevention and 28% to early intervention. Most programs were theory-driven and targeted one or more ED risk factors such as thin-ideal internalisation and/or body dissatisfaction. There is reasonable evidence to support prevention programs reducing risk factors, particularly as part of school or university-based programs, with established feasibility and relatively high acceptance among students. There is increasing evidence around the use of technology (to increase dissemination potential) and for use of mindfulness approaches (targeting emotional resilience). Few longitudinal studies assessing incident cases following participation in a prevention program exist.

CONCLUSIONS

Although several prevention and early intervention programs have been shown to significantly reduce risk factors, promote symptom recognition, and encourage help-seeking behaviour, most of these studies have been conducted in older adolescent and university aged students, past the age of peak ED onset. One of the most targeted risk factors, body dissatisfaction, is found in girls as young as 6 years old, indicating a need for further research implementing prevention initiatives at younger ages. Follow-up research is limited; thus, the long-term efficacy and effectiveness of studied programs is unknown. Greater attention should be paid to the implementation of prevention and early intervention programs in identified high-risk cohorts or diverse groups, where a more targeted approach may be necessary.

A comic-based body image intervention for adolescents in semi-rural Indian schools: Study protocol for a randomized controlled trial

Adolescents in India experience body dissatisfaction, however, empirically supported interventions are lacking. This paper describes the protocol for the development, acceptability testing, and cluster randomized controlled trial (RCT) of a six-session comic-based intervention, which aims to improve body image and related outcomes among adolescents in semi-rural Indian schools. If found to be acceptable and effective, UNICEF will disseminate the intervention across schools in eight states of India. The acceptability study will be conducted with 24 students in Classes 6-8 (age 11-14) and nine teachers from Hindi-medium government schools using interviews and focus groups. The subsequent RCT will be conducted with 2400 students, with schools randomized to either the comic-based intervention or lessons-as-usual (control) groups. The primary outcome is body esteem, and secondary outcomes are disordered eating, appearance ideal internalization, body-image-related life disengagement, self-esteem, negative affect, and positive affect. Additional exploratory outcome measures are skin colour dissatisfaction, body hair dissatisfaction, appearance-based teasing, and endorsement of traditional gender roles. These outcomes will be examined at three timepoints: baseline (T1), 1 week-post-intervention (T2), and 12-weeks follow-up (T3). Analyses will compare outcomes in the intervention with the control group. This will be the first study to evaluate a body image intervention for adolescents in semi-rural Indian schools.

Sustaining program implementation: A co-constructed technical assistance process to support continuous high-quality implementation of the Therapeutic Crisis Intervention program

Strategies for sustaining a program beyond initial implementation remain one of the most poorly understood aspects of high-quality program implementation. This paper describes the Quality Improvement and Fidelity Assessment Process (QIFAP), a program purveyor-agency partnership that uses a unique, multi-step method for supporting sustained implementation of the Therapeutic Crisis Intervention (TCI) system to manage crises in child serving organizations. It outlines the steps of the process and highlights how specific activities are linked to current knowledge and principles from implementation science. The QIFAP occurs over a period of about three months, during which time program developers and agency representatives conduct staff surveys, a two-day site visit, and fidelity assessments in order to gather information, discuss findings, and plan steps for improving the TCI system in the organization. The process is guided by principles that emphasize the importance of organization leadership, building relationships, co-learning, using an individualized approach, data informed decision making, acknowledging risk, and congruence. We describe ways in which the strategies and approaches within the QIFAP are rooted in implementation science literature. Thus, the model represents an illustration of how research-based knowledge can work in practice to support long-term, high-quality program implementation.

Dissonance-based eating disorder prevention among Brazilian young women: A randomized efficacy trial of the Body Project

A randomized controlled trial was conducted to assess the efficacy of the Body Project eating disorder prevention program in reducing eating disorder risk factors and symptoms in young Brazilian women. A total of 141 female university students aged 18-30 years old were randomly assigned to one of two conditions: assessment-only condition (n = 78) and Body Project condition (n = 63). Participants completed scales assessing body dissatisfaction, sociocultural influence, disordered eating attitudes and behaviors, eating disorders symptoms, body appreciation, depressive mood and negative affect at baseline, posttest, and at 1- and 6-month follow-ups. Body Project participants showed significantly greater reductions in body dissatisfaction, sociocultural influence, disordered eating, eating disorder symptoms, depressive symptoms, and negative affect, and greater increases in body appreciation (d = .35-.48) compared to assessment-only participants. Most of the effects persisted through 6-month follow-up (d = .35-.74). Results provide evidence that the Body Project is an effective intervention to reduce eating disorder risk factors and eating disorder symptoms among Brazilian young women, and that this intervention is naturally culturally adaptive.

Pathways into treatment for eating disorders: A quantitative examination of treatment barriers and treatment attitudes

Most individuals with eating disorders do not receive treatment for their eating disorder. Closing this "treatment gap" requires a quantitative examination of individuals' attitudes towards accessing various types of treatment and of individuals' perceived barriers to seeking treatment. Thus, we recruited a sample of 425 individuals with either diagnosed or undiagnosed eating disorders and asked them to complete a survey assessing treatment attitudes, treatment barriers, and eating disorder symptom severity. Undiagnosed individuals reported more positive attitudes towards novel Internet- and smartphone-delivered treatments, and stronger barriers relating to eating disorders mental health literacy, than diagnosed individuals. Nevertheless, both diagnosed and undiagnosed individuals were broadly more positive towards established (i.e., non-novel) treatments than novel treatments. The strongest barriers to seeking treatment were fear of losing control, fear of change, and finding motivation to change. Eating disorder symptoms were positively associated with the strength of most treatment barriers. Results were broadly unchanged after adjusting for individuals' past experiences of treatment. In conclusion, the development and dissemination of novel treatments and the provision of eating disorders mental health literacy may offer promising potential pathways into treatment for individuals with undiagnosed eating disorders. Nevertheless, researchers must pay attention to and improve, individuals' attitudes towards accessing these novel treatments. The positive correlations of symptom severity with treatment barrier strength highlights the importance of early intervention for individuals with eating disorders. Finally, the fear of losing control may be a uniquely salient treatment barrier for individuals with eating disorders that requires greater attention in future research on eating disorder treatment seeking.

Proposing a Mechanistic Model of Clinician Training and Consultation

To make evidence-based treatments deliverable, effective, and scalable in community settings, it is critical to develop a workforce that can deliver evidence-based treatments as designed with skill. However, the science and practice of clinician training and consultation lags behind other areas of implementation science. In this paper, we present the Longitudinal Education for Advancing Practice (LEAP) model designed to help span this gap. The LEAP model is a mechanistic model of clinician training and consultation that details how training inputs, training and consultation strategies, and mechanisms of learning influence training outcomes. We first describe the LEAP model and then discuss how key implications of the model can be used to develop effective training and consultation strategies.

From efficacy to effectiveness to broad implementation: Evolution of the Body Project

OBJECTIVE

At the turn of the millennium, eating disorders (EDs) prevention was largely nonexistent. No program had reduced future onset of EDs in even a single trial, and most had not reduced ED symptoms. Sixteen years later, the ED prevention field has translated basic risk factor research into interventions, with demonstrated efficacy and effectiveness in reducing ED risk factors and symptoms, as well as future ED onset in some trials. This article reviews the aforementioned progress focusing on a model intervention (i.e., the Body Project [BP]).

METHOD

The article is a qualitative review of the existing BP literature.

RESULTS

Although clinical psychology has struggled with bridging the research practice gap and translating efficacy and effectiveness research into clinical implementation, researchers, clinicians, and community stakeholders working with the BP have made significant progress in addressing barriers to scalability, large-scale implementation, and sustainability, reaching 3.5 million girls and young women in 125 countries.

CONCLUSION

The successful evolution of the BP from basic research to traversing the efficacy-to-effectiveness-to-dissemination/implementation continuum has yielded significant public health impact and is thus a fitting case for this special issue commemorating the 125th anniversary of the American Psychological Association. The BP example may help others broadly implement efficacious interventions for other mental health problems. (PsycINFO Database Record

From Efficacy to Global Impact: Lessons Learned About What Not to Do in Translating Our Research to Reach

Although members of the Association for Behavioral and Cognitive Therapies have made significant strides toward the collective goals outlined in our mission statement, we routinely acknowledge that our ability to develop empirically supported treatments exceeds our success in improving dissemination and implementation of said interventions. Further, as noted by Kazdin and Blase (2011), even if we succeeded in having every clinician worldwide administer our best treatments with excellent competency, we still would be unsuccessful in markedly impacting the worldwide burden of mental illness because most treatments require intensive labor by expensive providers. To this end, Kazdin and Blase and others call for increased use of alternative strategies. Examples include increased attention toward prevention; use of lower-cost, simplified interventions; task shifting; train-the-trainer models; community participatory research methodology; and identification of novel funding sources. The Body Project is an empirically supported, cognitive dissonance-based prevention intervention that targets body image, a well-established risk factor for eating disorders, negative affect, unhealthy weight control behaviors, smoking behavior, and decreased physical activity. Supported by a global village of researchers, community activists, and organizational partners, the Body Project is currently being implemented in 125 countries. The aim of this paper is to share lessons our team has learned in taking a prevention intervention from early testing to widespread implementation and connect these back to broader conversations occurring in our field regarding the importance of scalability and new directions in improving global mental health.

Lessons learned from training peer-leaders to conduct Body Project workshops

The Body Project is a cognitive-dissonance intervention that is effective in improving body satisfaction for high school and college aged women. The Body Project can be implemented by trained peers, thus increasing its potential for broad and cost-effective dissemination. Little is known, however, about peer-leaders' perceptions of their training needs and preferences to deliver prevention programs. This qualitative study explored the perceptions of training strengths and areas of improvement among 14 Body Project peer-leaders at a college campus through a series of focus groups. Recommendations are made to inform training for the Body Project as well as peer-led prevention and treatment interventions more broadly.

Addressing critical gaps in the treatment of eating disorders

Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: (1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and (2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.

The body project 4 all: A pilot randomized controlled trial of a mixed-gender dissonance-based body image program

OBJECTIVE

The Body Project is a cognitive dissonance-based body image improvement program with ample research support among female samples. More recently, researchers have highlighted the extent of male body dissatisfaction and disordered eating behaviors; however, boys/men have not been included in the majority of body image improvement programs. This study aims to explore the efficacy of a mixed-gender Body Project compared with the historically female-only body image intervention program.

METHOD

Participants included male and female college students (N = 185) across two sites. We randomly assigned women to a mixed-gender modification of the two-session, peer-led Body Project (MG), the two-session, peer-led, female-only (FO) Body Project, or a waitlist control (WL), and men to either MG or WL. Participants completed self-report measures assessing negative affect, appearance-ideal internalization, body satisfaction, and eating disorder pathology at baseline, post-test, and at 2- and 6-month follow-up.

RESULTS

Linear mixed effects modeling to estimate the change from baseline over time for each dependent variable across conditions were used. For women, results were mixed regarding post-intervention improvement compared with WL, and were largely non-significant compared with WL at 6-month follow-up. Alternatively, results indicated that men in MG consistently improved compared with WL through 6-month follow-up on all measures except negative affect and appearance-ideal internalization.

DISCUSSION

Results differed markedly between female and male samples, and were more promising for men than for women. Various explanations are provided, and further research is warranted prior to drawing firm conclusions regarding mixed-gender programming of the Body Project. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:591-602).

Integrating intervention targets offered by homeostatic theory

Marks presents "homeostatic theory" which proposes that weight gain is fostered by a "Circle of Discontent" consisting of body dissatisfaction, negative affect, and overconsumption. This innovative framework offers potential intervention approaches, including victim-blaming, stigma, and discrimination, as well as devalorizing the thin-ideal. Our article discusses possible ways that clinical health psychologists based in university settings may be uniquely positioned to consider and implement large-scale programs that have shown great promise for addressing these core issues.