Engaging Stakeholder Communities as Body Image Intervention Partners: The Body Project as a Case Example

Abstract

Despite recent advances in developing evidence-based psychological interventions, substantial changes are needed in the current system of intervention delivery to impact mental health on a global scale (Kazdin & Blase, 2011). Prevention offers one avenue for reaching large populations because prevention interventions often are amenable to scaling-up strategies, such as task-shifting to lay providers, which further facilitate community stakeholder partnerships. This paper discusses the dissemination and implementation of the Body Project, an evidence-based body image prevention program, across 6 diverse stakeholder partnerships that span academic, non-profit and business sectors at national and international levels. The paper details key elements of the Body Project that facilitated partnership development, dissemination and implementation, including use of community-based participatory research methods and a blended train-the-trainer and task-shifting approach. We observed consistent themes across partnerships, including: sharing decision making with community partners, engaging of community leaders as gatekeepers, emphasizing strengths of community partners, working within the community’s structure, optimizing non-traditional and/or private financial resources, placing value on cost-effectiveness and sustainability, marketing the program, and supporting flexibility and creativity in developing strategies for evolution within the community and in research. Ideally, lessons learned with the Body Project can be generalized to implementation of other body image and eating disorder prevention programs.

In a seminal 2011 paper, Kazdin and Blase argued that psychotherapy needs to be “rebooted” if the field ever hopes to address the global burden of mental illness. They noted that expert-led psychotherapy, the dominant form of mental health intervention, is too expensive to address the needs of everyone with mental illness, even if every therapist worldwide only delivered empirically supported interventions. They proposed several solutions including: increasing focus on prevention, addressing the continuum of care, using task-sharing/shifting with layperson providers, and increasing cross-disciplinary partnerships.

As Kazdin and Blase (2011) note, prevention already leads treatment in addressing their concerns. For instance, prevention more explicitly addresses a continuum of care via classification of interventions as universal (i.e., to an entire population), selective (i.e., to those at risk), and targeted/indicated (i.e., to those expressing early symptoms: Mrazek & Haggerty, 1994). Yet, both the eating disorders prevention and body image intervention fields, which often target similar psychosocial influences, also fall prey to various traps described by Kazdin and Blase. Specifically, most of our interventions use an expert-led approach targeting a limited range of high-risk individuals, typically young women with pre-existing body image concerns.

The Body Project (TBP) is a body image intervention with extensive empirical support (see below). Although much of the research supporting TBP (e.g., Stice, Rohde, Butryn, Shaw, & Marti, 2015; Stice, Rohde, Shaw, & Gau, 2011; Stice, Shaw, Burton, & Wade, 2006) is selective, TBP also has been implemented with lower-risk populations. For instance, some studies and dissemination efforts targeted mixed-risk groups (e.g., those with low and elevated body image concerns: Becker, Bull, Schaumberg, Cauble, & Franco, 2008; Becker et al., 2010); adolescent girls in western and non-western countries (http://www.free-being-me.com/); and males (Brown & Keel; 2015; Jankowski, Diedrichs, Fawkner, Gough, & Halliwell, submitted; Kilpela et al., submitted). Further, TBP community has embraced other suggestions proposed by Kazdin and Blase, including task-shifting to lay providers and utilizing community participatory research (CPR) methodology to foster effective partnerships with stakeholders.

Herein we aim to describe the diverse stakeholder partnerships that have advanced the research and dissemination/implementation of TBP worldwide so as to help other intervention developers establish effective partnerships. We first briefly review the empirical evidence supporting TBP because all current partners report finding the strong evidence base, as well as program acceptability, critically important; we also describe our current leadership structure. We then provide a background on CPR. Next, we discuss key partnerships that have played a critical role in the study and implementation of TBP and highlight lessons learned from each partnership. Although we have tried to avoid redundancy, common themes in the lessons learned (e.g., creating mutual benefit and return on investment) are underscored.

Kazdin and Blase (2011) argue that cross-disciplinary partnerships are essential to reducing the burden of mental illness. Our experiences suggest that such partnerships bring new ideas to the table, elucidate novel avenues for implementation, and create opportunities for changing behaviors at a macro/community level. We hope this paper facilitates dissemination and implementation of other empirically supported prevention programs.

1.1 Body Project Empirical Support and Leadership Structure

TBP is a cognitive dissonance-based intervention in which young women voluntarily critique the thin-ideal standard of female beauty via verbal, written, and behavioral exercises. This theoretically creates the uncomfortable psychological state of cognitive dissonance, which prompts participants to reduce thin-ideal internalization because people are motivated to align their attitudes with their behaviors (Festinger, 1957). Reduced thin-ideal internalization putatively decreases body dissatisfaction, eating disorder symptoms, and eating disorder onset (Stice, Becker, & Yokum, 2013). TBP has produced larger reductions in thin-ideal internalization, body dissatisfaction, dietary restraint, and eating disorder symptoms than assessment-only control conditions and alternative interventions in multiple efficacy trials with a range of follow-up times out to 3-years (Becker, Smith, & Ciao, 2005; Green, Scott, Diyankova, Gasser, & Pederson, 2005; Halliwell & Diedrichs, 2014; Matusek et al., 2004; Mitchell, Mazzeo, Rausch, & Cooke, 2007; Stice et al., 2003, 2006, 2008). TBP also yielded a 60% reduction in eating disorder onset relative to assessment-only at 3-year follow-up in the largest efficacy trial (Stice et al., 2008). Furthermore, effectiveness research indicates that TBP can be successfully delivered by undergraduate peer-leaders (Becker et al., 2006; 2008; 2010).

Research supports the theory underpinning TBP. Reductions in thin-ideal internalization mediated the effects of TBP on symptom reductions in Seidel et al. (2009) and Stice et al. (2007) and participants assigned to high- versus low-dissonance induction versions of TBP show greater symptom reductions (Green et al., 2005; McMillan et al., 2011). TBP also eliminated negative effects of exposure to thin models on body dissatisfaction (Halliwell & Diedrichs, 2014). Lastly, TBP participants showed a greater pre-post reduction in fMRI-assessed reward region (caudate) neural responsivity to thin models and attention region (anterior cingulate) response to thin-ideal statements than controls (Stice et al., 2013).

TBP is currently implemented worldwide and is supported by a global community of researchers, clinicians, stakeholder organizations, and body image activists. We maintain a loose leadership structure. More specifically, anyone can study and implement TBP simply by buying the official manual or by downloading free scripts from www.bodyprojectsupport.org. Despite this, we strongly recommend (but don’t require) that new members to our community receive training to maximize program effectiveness, particularly when working with lay providers (e.g., peer leaders; teachers); we also request that people keep Drs. Becker and Stice informed as to their work with TBP. There is no formal mechanism for people to do this, however; rather stakeholders stay in touch to the degree they desire via email and at conferences. In 2012, we established the Body Project Collaborative (BPC) to create training infrastructure. The BPC consists of highly experienced TBP trainers and researchers. To simplify language, we will describe current partnerships as occurring between the BPC and other organizations for the rest of the paper.

1.2 Community Participatory Research (CPR)

In contrast to traditional research, in which researchers develop an idea and then recruit participants, CPR engages community stakeholders in sharing decision making and power (Israel, Eng, Shculz, & Parker, 2005). CPR seeks to improve problem solving and increase knowledge by integrating multiple perspectives (Israel et al., 2005; Shoultz et al., 2006). We use the term CPR to describe how we approach partnerships regardless of whether or not we expect them to be focused primarily on intervention implementation, research, or both. Israel et al. (2005) describe nine major facets of CPR. These include: acknowledging that communities consist of individual members who have connection to the community; building on community strengths; developing equitable and collaborative partnerships; advancing capacity building and co-learning for all; balancing joint demands of creating new knowledge with providing useful intervention; recognizing that health problems are currently troublesome for communities; engaging in a collaborative, cyclical and iterative process; sharing results in a way that respects stakeholders and provides useful information; and developing long term commitment to the project, community and sustainability

1.3 Partnerships

1.3.1 Universities

Universities represent one of the largest cohorts of TBP implementers. In this section we describe several university-focused partnerships to illustrate how a variety of collaborations enhance TBP implementation.

1.3.1.1 Sororities

TBP global community is the culmination of over 10 years’ evolution, integrating CPR methodology and scientific rigor. Our partnerships with sororities highlight the critical importance of CPR methods and the importance of creating sustainable strategies for implementation. The initial partnership was developed with local sororities (i.e. exist only at one institution) at a small university in 2001, with the goal of replicating Stice and colleagues’ (2000) early TBP findings. Working with gatekeepers (i.e., individuals who belong to and can access members of a community), we conducted a pilot trial of TBP with sorority members who screened for elevated body dissatisfaction (Becker et al., 2002). After the trial, in what turned out to be our first step using CPR methodology, we invited former participants to offer feedback and suggestions. Participants reported wanting more sorority members to complete the program. Accordingly, we eliminated the screening procedure and tested whether TBP yielded positive effects when implemented universally. At the time, some researchers were concerned about universal implementation (e.g., Mann et al., 1997). Results from the second trial demonstrated that TBP was beneficial regardless of risk status (Becker et al., 2005).

During the next feedback session, community members requested broader implementation. Of note, we conducted this sorority research without substantial funding or sufficient expert providers to deliver TBP. Thus, we faced our first mismatch between community needs and available resources. To address this, we used task-shifting, which involves delivering interventions via non-expert providers (Patel, Chowdhary, Rahman, & Verdeli, 2011). Specifically, we task-shifted implementation of TBP to trained undergraduate peer-leaders. Thus, CPR methodology (Becker, Stice, Shaw, & Woda, 2009) played a critical role in the evolution of TBP; several studies subsequently demonstrated TBP delivery could be task-shifted to undergraduate students (Becker et al., 2006; 2008; 2010; Perez et al., 2010).

Following early growth with local sororities, we partnered with a national sorority to disseminate TBP in North America. In 2008, after three years of relationship building and piloting, the Tri Delta sorority launched a large dissemination project using the task-shifted, peer-led version of TBP. Early on, however, we determined that task-shifting alone was insufficient to achieve our collective goals because relying on 1–2 expert trainers limited program scalability secondary to time constraints and the cost of flying trainers to different universities. We then adopted a train-the-trainer model (TTT: Zandberg & Wilson, 2012) to enhance TBP scalability. In the TTT model, expert (typically expensive) providers (e.g., psychologists with eating disorder expertise), train moderately-expert/expensive providers (e.g., university health staff) to train other providers (e.g., students) in the delivery of an evidence-based intervention. The TTT model decreases costs (thus increasing sustainability), decreases travel and scheduling demands, and builds capacity within individual organizations for sustainable delivery (e.g., universities). Thus, in collaboration with our community partners, we developed a blended task-shifting/TTT approach for implementation of TBP. In a proof-of-concept study, we demonstrated that use of the blended task-shifting/TTT approach produced comparable results to the expert-trained, peer-led version of TBP on participant outcomes and protocol adherence (Kilpela et al., 2014).

Regarding lessons learned, one early lesson involved the importance of actively listening to, and respecting the needs, opinions, and expertise of stakeholders. This allowed us to tailor our messaging about TBP so that it fit with stakeholder values and addressed perceived implementation barriers, which improved such implementation outcomes as acceptability, adoption, feasibility and sustainability (Proctor et al., 2011). Second, we learned to identify and highlight our community partners’ strengths (e.g., organization, experience delivering programs at scale), as opposed to perceived weaknesses and negative stereotypes. Third, we discovered the powerful role of gatekeepers (e.g., specific sorority members who served as liaisons and partners) and the importance of recruiting community members onto the research/implementation team. Last, we learned that operating under real world, sustainable conditions facilitated creative solutions (e.g., task-shifting/TTT) and raised interesting research questions. Importantly, the above lessons provided a foundation for all subsequent partnerships.

1.3.1.2 Eating Recovery Center Foundation (ERCF)

The partnership with ERCF points to the value of pursuing novel partnerships with a wide array of organizations and the importance of managing costs. In 2013, the BPC launched a pilot partnership with the ERCF, which is the non-profit arm of the residential eating disorder treatment program, the Eating Recovery Center (ERC). ERCF was primarily interested in helping to facilitate implementation of TBP at universities. Although some universities implement TBP via clinicians, most use the task-shifting peer-leader approach described below, which meets a common university goal of creating student leadership opportunities. To optimally implement in this manner, most campuses partner with the BPC for a one time, 2-day, TTT training in which a starter cohort of peer-leaders is train along with staff who then sustainably train subsequent generations of peer-leaders. For this pilot, the ERCF created grants to help North American universities offset the cost of bringing a trainer to campus to launch the sustainable TTT/task-shifting peer-leader model. A TBP trainer who worked at ERC originally proposed this partnership, and subsequently stimulated negotiation with ERCF leadership and Dr. Becker.

The 2-phase pilot facilitated expansion of TBP to 10 new universities over 18 months. At the end of the pilot, based on mutual satisfaction with the partnership, the BPC and ERCF signed an exclusive North American agreement which will fund expansion of TBP to another 85 universities over 5-year period. The 85 grants will make it possible for universities to receive the 2-day training for as little as $500 out-of-pocket expense.

We learned three lessons from our partnership with ERCF. First, prevention developers can find new partner organizations with financial resources to support dissemination and implementation, assuming their missions align. We believe that the ERCF chose to partner with the BPC for two primary reasons, in addition to their mission to “give back.” First, TBP’s strong empirical base suggested that the resources ERCF invests will yield positive outcomes; ERCF clearly wanted their contribution to have a positive impact. Second, those positive outcomes and TBP brand can potentially help name recognition for both the non-profit foundation and the for-profit company. In essence, TBP increases their brand equity.

With regards to the second lesson, cost matters to many stakeholder communities. Although some universities can allocate resources for our one-time TTT training, reducing cost via grants has opened new doors. Third, we can outreach to universities (i.e., cold call/email), and successfully bring TBP to campuses that previously did not plan on running TBP, rather than awaiting interest.

1.3.1.3 Arizona State University (ASU)

Although TBP has been implemented on over 100 university campuses, ASU represents one of the largest roll outs to date, with hundreds of students completing the program per semester. ASU also stands out regarding significant non-financial support from administrators. In this section, we highlight a number of strategies/lessons that played a role in success at ASU, including the importance of marketing and linking TBP to broader institutional goals.

First, consistent with CPR, we aligned the program with the community’s mission. For example, to improve adoption, prior to approaching ASU constituents, Dr. Perez assessed the impact of the program’s target variables (e.g., body dissatisfaction) on ASU students via a research study. She then provided digestible statistics to administrators demonstrating how body dissatisfaction impaired academic achievement (e.g., “approximately, 33% of ASU women would rather fail an assignment than give a presentation in front of class due to body image concerns”). Additionally, she repackaged peer facilitator language to align with the university’s mission by emphasizing that TBP would not only assist in creating a healthy community, but also would infuse the university with female leaders. Tying TBP to institutional goals made it more attractive and palatable to administrators.

Another ASU lesson is the importance of marketing to improve adoption. Specifically, prior to implementation, the ASU TBP team engaged in a year-long marketing campaign aimed at constituents within ASU. They developed a 5-minute, interactive “pitch” to engage participants and expand discussions about TBP at ASU. This pitch was delivered by charismatic individuals and tailored to each sub-community (e.g., undergraduate students, staff at residence halls, student counseling center). Another marketing component included having audiences experience one or two of the fun interactive TBP activities to give the audience an idea of what the program is about and simultaneously sell the program.

The final strategy involved adding elements to our research study that assisted administrators. A key struggle on college campuses for any program is getting students to participate. We are employing and testing various cost-effective incentive strategies, and we share results with university officials.

In sum, ASU lessons include the value of an organized marketing plan. ASU also demonstrates how connecting TBP to larger university concerns, values and goals increased stakeholder buy-in. This extends to designing research studies that not only address questions relevant to TBP but also other university programs.

1.3.2 Foundations

1.3.2.1 Dove, WAGGGS and the Free Being Me

In 2012, the Dove Self Esteem Project (DSEP) embarked upon an update of their educational programs with the aim of utilizing best practices for improving body image. Dove also sought partnerships with key organizations to maximize global scalability and impact. Ultimately, they decided to fund and implement a global body image program for young girls with the World Association of Girl Guides and Girl Scouts (WAGGGS), which is the world’s largest youth organization for girls. Our partnership with Dove and WAGGGS showcases the value of a) bringing together very different constituencies towards a common goal and b) respecting the different strengths of each constituency.

In consultation with Dr. Diedrichs, who served on the DSEP advisory board and had extensive TBP experience, WAGGGS and Dove chose TBP as the foundation for their new program, Free Being Me (http://www.free-being-me.com). This decision was based on a) TBP’s extensive evidence base, b) TBP’s focus on providing girls with opportunities to speak against sociocultural pressures, demonstrate leadership, and engage in community activism, which are consistent with WAGGGS’ values, and c) past evidence of successful TBP partnerships using CPR. Accordingly, members of the DSEP, WAGGGS, and Dr. Diedrichs worked closely with Drs. Stice and Becker using an iterative process to adapt TBP to meet the needs of WAGGGS’ non-formal education approach and global multicultural population. With the assistance of Drs. Diedrichs and Becker, WAGGGS subsequently created their own TTT model, with global trainers delivering national trainings around the world, after which trainees cascaded training down to local organizations.

Enthusiasm for Free Being Me from WAGGGS’ member organizations has been enormous. Since November 2013, 120 countries across six continents have adopted Free Being Me, which is now available in 16 languages. WAGGGS reports that over two million girls and boys have received the program in some form. WAGGGS also recently partnered with Drs. Diedrichs and Stice to conduct global dissemination and implementation research to understand the uptake and effectiveness of Free Being Me, creating the first global body image dissemination/implementation study.

Regarding lessons learned, this partnership taught us that global dissemination of evidence-based body image interventions will necessitate different constituencies learning to work together flexibly and creatively; in this case a multinational brand with a social mission, a global youth organization, and body image researchers. We also learned that it pays to recognize and respect the diversity of strengths that different members of TBP community have developed (e.g., Stice: manual format and lessons from early testing, Becker: TTT model and CPR, Diedrichs: partnership expertise/trust with Dove and WAGGGS) as well as the strengths of our partners (e.g., WAGGGS: non-formal education, Dove: global reach and resources), and to work together to maximize what we can collectively accomplish.

1.3.2.2 National Eating Disorders Association (NEDA)

The BPC and NEDA partnership once again highlights the importance of cost-effective, scalable models as well as the utility in partnering with grassroots organizations. We began this partnership in 2012 with discussions about the adaptability of the TTT model to NEDA’s infrastructure and possibilities for financial support. NEDA expressed interest in the program because it fit with NEDA’s longstanding goal of advancing prevention; this goal previously had been sidelined because of the lack of evidence-based programs. Thus, NEDA’s interest in TBP was rooted in a) the evidence base and b) their sense TBP it fit with other initiatives (e.g., NEDA’s positive web-based community proud2bme.org) and would be a good investment of resources. Together, we submitted several grants and ultimately were funded initially to bring TBP to underserved high school girls in New York City (NYC).

To establish NEDA’s base with TBP, we conducted three 2-day TTT sessions to train both layperson group facilitators and trainers of group facilitators. We also trained two NEDA staff as “master” trainers in TTT training for future program expansion. To date, NEDA has delivered TBP to high school girls in NYC per the original charter of the grant. They also have engaged in outreach to community-based organizations and will expand delivery of TBP in NYC. Additionally, NEDA is offering a full day of facilitator training as a pre-conference workshop for the annual NEDA conference. Demand for training was so high that they added an additional training session to their 2015 annual meeting.

Our partnership with NEDA again highlights the importance of the TTT model. Specifically, being self-sufficient and able to sustainably scale-up delivery were essential to NEDA. Additionally, we observed the benefits of connecting to an organization’s existing values and programming. For instance, the ability to link TBP’s messages directly to Proud2BMe allowed two seemingly independent endeavors to work symbiotically. Lastly, this partnership highlights the advantages of building relationships with grass-roots organizations.

1.3.2.3 Comenzar de Nuevo (CdeN)

The BPC partnership with CdeN, a Mexico-based not-for-profit foundation for eating disorders treatment, demonstrates the importance of: global professional organizations, integration of business models, marketing, and using the TBP to advance broader research agendas. This partnership began after a TBP workshop conducted at the Academy of Eating Disorders (AED) International Conference for Eating Disorders. Dr. Trujillo and a colleague approached Dr. Becker about forming a partnership; importantly all three individuals were long standing members of AED and had previously networked through the organization, which facilitated partnership development. CdeN’s interest in TBP was rooted in its utility for community outreach and giving back as well as the evidence-base, which made them feel confident that resources would be well spent. TBP also furthers CdN’s foundation goal of advancing prevention in the Latin American community.

A key aspect to the success of this partnership has been the development of a sustainable business model. Although other partnerships have sought to reach relatively large populations of individuals, CdeN is the first non-profit to set a goal of reaching hundreds of thousands in multiple countries with TBP despite not currently having the infrastructure to do so (e.g., Dove/WAGGGS partnership is supported by generous funding from a major corporation and built on WAGGGS existing infrastructure). To accomplish this, CdeN recruited two business executives from Mexico to create a business model with a 3-year plan towards self-sustainability. The development of the business plan required extensive collaboration between the business executives, the BPC, and CdeN. The BPC had to re-analyze data collected during previous trials and implementation efforts in novel ways, share financial data with the business executives to check assumptions, and provide expertise about implementation.

After developing the business plan, CdeN hired a marketing agency and started a marketing plan targeting Mexico and Latin America that included a) developing an educational video about TBP and fat talk that is being shared via a social media campaign, b) placing brochures in public spaces, schools and universities, and c) advertising via local and national TV, newspapers and radio. Marketing also included adapting the concept to Latin culture by translating most of the BPC webpage into Spanish webpage www.hagamosbip.net. Although CdeN’s business plan starts locally with later expansions to the rest of Mexico and all of Latin America, CdeN began immediate marketing beyond the local region to generate interest. Relying again on relationships often built through the Hispano Latino American Chapter of the AED, CdeN organized a network of colleagues to promote the program in other countries. Lastly, CdeN created an “adopt a school” program linking foundations and companies with public schools to help bring TBP to those schools.

As with other partnerships, we again have seen the importance of linking TBP to other initiatives that resonate with our partners. For instance, the eating disorders field currently has limited research on what aspects of prevention programs are effective across cultures. Thus, as part of our partnership with CdeN, we are collecting both quantitative and qualitative data on Mexican and Latino participants’ experiences with the hope of answering key questions for the globalization of prevention. We also plan to use the program as a platform to facilitate other research projects that are of interest to Latin American partners.

1.4 Challenges in Partnering with Stakeholder Communities

Although we believe that advancing universal prevention requires developing partnerships with an array of stakeholder communities, we would be remiss if we did not identify some of the challenges researchers might encounter in such work. First, developing such partnerships is time consuming and often researchers’ time is not compensated during the early stages partnership of development. Second, even some successful partnerships break down over time. For instance, secondary to staffing changes, which can happen with any stakeholder community, Tri Delta decided in 2012 that it only wanted to focus on programming for its members. This decision countered the original agreement between Dr. Becker and Tri Delta; this change in Tri Delta’s goals ultimately led to the end of that partnership. Third, large scale dissemination requires some degree of infrastructure (e.g., people to respond to questions, a business plan, development of contracts, marketing). On the one hand, it can be really beneficial to allow stakeholder partners to take the lead in this area. On the other hand, one risks losing all infrastructure if the partnership dissolves; indeed this is what happened with Tri Delta. For this reason, we now adopt a middle road approach, where we have created some of our own infrastructure via the Body Project Collaborative, which is then augmented by stakeholder partners for certain geographical regions or special populations. Maintaining infrastructure, however, is also time consuming and often done on at least a partially volunteer basis.

1.5 Conclusion

During the last decade and a half, members of the BPC have been fortunate to work with a diverse group of stakeholder communities who valued the strong evidence-based for TBP. We are sure that we have learned as much, if not more, from our partners than they learned from us. It is beyond the scope of this paper to detail all of the ways in which our partners have helped us improve our implementation outcomes; yet one overarching lesson is that many stakeholder communities have an array of skills, resources, experience, and knowledge that directly addresses many of the barriers that often prevent researchers from achieving successful implementation. To benefit, however, researchers need to take the time to form relationships, listen and learn. Our primary aim in writing this paper was to share lessons learned so that other intervention developers might benefit from our experiences. We fully believe that each successful partnership has laid vital groundwork for subsequent partnerships and hope that future researchers can use the case study of TBP to advance dissemination and implementation of other programs.

Highlights.

• The Body Project is an evidence-based program

• The Body Project is globally implemented in partnership with community stakeholders

• Community participatory methods played a key role in development of partnerships

• Attention to cost-effectiveness and sustainability is important to stakeholders