Protocol of a cluster randomised trial of BodyKind: a school-based body image programme for adolescents

(2023) 23:2246 Mahon et al. BMC Public Health https://doi.org/10.1186/s12889-023-17002-x BMC Public Health Open Access STUDY PROTOCOL Protocol of a cluster randomised trial of BodyKind: a school‑based body image programme for adolescents Ciara Mahon1* , Denise Hamburger2, Jennifer B. Webb3, Zali Yager4 , Emma Howard5 , Ailbhe Booth1,6   and Amanda Fitzgerald1    Abstract Background Poor body image is prevalent among adolescents and associated with several negative outcomes for their physical and psychological health. There is a pressing need to address this growing public health concern, yet there are few evidence-informed universal programmes for older adolescents that address contemporary body image concerns (i.e., social media). BodyKind is a four lesson, school-based, teacher led, universal body image programme that incorporates empirically supported principles of cognitive dissonance, self-compassion, compassion for others and social activism, to support positive body image development. Building on previous pilot trials in the USA, this paper outlines the protocol for a cluster randomised control trial (cRCT) and implementation evaluation of the BodyKind programme which was culturally adapted for the Irish cultural context. Methods We aim to recruit 600 students aged 15-17 years in Transition Year (4th year) across 26 second-level schools in Ireland. Using minimisation, schools will be randomly assigned to receive BodyKind (intervention condition, n=300) or classes as usual (waitlist control, n=300). Teachers in intervention groups will receive training and deliver the programme to students over four weeks, at a rate of one lesson per week. Primary outcomes of body appreciation, body dissatisfaction and psychological wellbeing and secondary outcomes of self-compassion, compassion for others, body ideal internalisation, social justice motives and appearance-based social media use will be assessed at pre-, post- and 2 month follow up. Mediation and moderation analyses will be conducted to identify how and for whom the intervention works best. An implementation evaluation will assess the quality of programme implementation across schools and how this may influence intervention outcomes. Waitlist control schools will receive the programme after the 2-month follow up. Conclusion This study will be the first to implement a cRCT and an implementation evaluation to assess the impact of this multicomponent school-based body image programme designed to support healthy body image development. If shown to be effective, BodyKind will have the potential to improve adolescent body image and wellbeing and inform efforts to implement sustainable and scalable programmes in schools. Trial registration The trial was retrospectively registered on 10/10/2023 on ClinicalTrials.gov NCT06076993. Keywords Body image, Adolescent, Intervention, Protocol, School-based, Psychological wellbeing, Body dissatisfaction, Randomised control trial, Implementation evaluation *Correspondence: Ciara Mahon Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Mahon et al. BMC Public Health (2023) 23:2246 Background Body image concerns are prevalent among adolescents, with an estimated 75% of young people reporting body image distress worldwide [1]. Body image concerns are associated with several negative outcomes for physical health [disordered eating/exercise [2, 3] and psychological wellbeing [low self-esteem, negative affect [3, 4] and are a primary modifiable risk and maintenance factor for eating disorders [5, 6]. Body image concerns and eating disorders have increased over the last decade [1, 7], particularly since the Covid-19 pandemic, with some studies reporting almost a doubling in the incidence of eating disorder related care in 2019 for adolescents compared with previous years [8–10]. Similarly in Ireland, less than half of adolescents are satisfied with their appearance [11] and a 66% increase in acute hospital admissions for eating disorders was observed among young female adolescents in Ireland between 2019-2020 [12]. Effective prevention is required to reduce the burden of disease and support adolescent psychological wellbeing [13]. Universal eating disorder prevention, which addresses all levels of risk, are often delivered in schools as they provide a cost-effective and inclusive way to access a wide range of adolescents within a sustained, learning environment [13, 14]. Traditionally, eating disorder prevention approaches have targeted risk factors for body image concerns [15], such as body ideal internalisation [i.e., cognitively endorsing body ideals as personal body standards [16] and appearance comparisons [i.e., comparing oneself on dimensions of appearance [17], which according to the Tripartite Model of Body Image [18], mediate the relationship between sociocultural appearance pressures (e.g., social media, peers, family) and the development of body image concerns. There is considerable evidence that such cognitive dissonance approaches [19], which involve publicly criticising unrealistic body ideals reduce the pursuit (internalisation) and comparison with these ideals, are effective in reducing adolescent body dissatisfaction in school-based trials [14, 15, 20, 21]. Recently, prevention approaches have acknowledged the importance of promoting positive body image, in addition to countering body dissatisfaction [22]. Positive body image, which is operationalised as body appreciation, is a unique, holistic construct which involves respecting, appreciating, nurturing and caring for one’s body and honouring natural body diversity [23], and is independently associated with benefits for physical and psychological health [e.g., greater adaptive coping, life-satisfaction, self-care behaviours [22– 24]. Self-compassion represents a promising approach for supporting body appreciation and psycholog (...truncated)