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 psychological wellbeing (25,26). Self-compassion is an emotional regulation strategy (28) that enables individuals to self-soothe by reframing self-critical thoughts and shame that are at the root of body dissatisfaction (27). Self-compassion also helps individuals to appreciate alternative aspects of themselves (rather than overvaluing appearance) to promote positive body image (28,29). Self-compassion interventions are found to be effective in supporting adolescent psychological wellbeing (30,31) and there is growing evidence that they show promise for improving body appreciation in adolescents (32–34).
Additionally, social justice perspectives (35), advocate that eating disorder prevention should move beyond the individual, to target the broader structural and social inequities inherent in diet culture that initiate and perpetuate appearance concerns in the first place (36). Within the classroom context, where peers are present, empowering adolescents to challenge appearance biases (where people are treated differently based on how they look versus how they are as a person) and to engage in prosocial, compassionate behaviours towards others, such as challenging peer norms or reducing body talk/body shaming, could represent an approach to develop a supportive context for positive body image development (37–40). However, further research on social justice motives and prosocial body image behaviours as pathways to building positive body image in adolescents is required (37).
While progress has been made in school-based body image intervention approaches, many gaps remain; firstly, most existing evidence-based programmes target early adolescents (12–13-year-olds), but there are fewer programmes that address body image concerns of older adolescents, despite the finding of the peak onset of eating disorders is between mid-late adolescence (41). Additionally, many existing programmes fail to address contemporary adolescent body image concerns, such as social media-related concerns [although there are exceptions, (42,43)], or do not focus on the body image concerns of males and adolescents across the gender spectrum (44,45). Also, many interventions are researcher-led, and there is a need for scalable and self-sustainable effective programmes that are teacher-led and that work towards building contexts to support positive body image development (36,44).
Be Real’s BodyKind is a four-session, teacher-led, gender-inclusive school-based programme for adolescents aged 15–17 years that targets contemporary body image issues for adolescents (e.g., social media, gender inclusivity). This multicomponent intervention combines, for the first time, empirically supported principles of cognitive dissonance, self-compassion and social activism and is anticipated to enhance body image outcomes by facilitating various mechanisms of change to occur [outlined elsewhere in a Logic Model (46)]. BodyKind was originally developed for high schools in the USA, with goals for broader, global implementation should the programme prove efficacious. Preliminary trials in the USA indicate the acceptability and feasibility of the BodyKind programme (46). To facilitate the next phase in the development/evaluation of complex interventions, a rigorous cluster randomised trial cRCT evaluation across multiple sites is required (47).
To this end, BodyKind was culturally adapted to the Irish context via a series of codesign workshops with adolescents (n = 12, 15–16 years) and interviews with teachers (n = 6) and a clinician (n = 1) to optimize intervention effects(48) After receiving the BodyKind programme, students shared perceptions of programme acceptability and codesigned content to ensure its cultural relevance to the Irish context (e.g., examples/scenarios that are relevant for young people in Ireland) (50,91). Teacher feedback was used to facilitate implementation in schools (i.e., scheduling content delivery across 40–60-minute class durations, and to ensure content aligned with the Department of Education and Skills Wellbeing Policy Statement and Framework for Practice). The programme was considered highly acceptable by teachers and students, with 82% of students stating that they enjoyed the lessons and 73% would recommend the programme to a friend. A female clinician from Jigsaw, The National Centre for Youth Mental Health, was also consulted to ensure the programme aligned with Jigsaw’s ethos for supporting youth mental health in Ireland. Cultural adaptation protocols and details of changes made to the programme are outlined elsewhere.
The current paper describes the protocol for a cluster randomised control trial cRCT, which will be conducted in Irish schools with 4th year second-level students (aged 15–17 years) to evaluate the effectiveness of the culturally adapted BodyKind programme in improving body image and mental health outcomes among adolescents in Ireland. Schools will be randomly assigned to intervention or waitlist control conditions (14,42). Teachers in the intervention condition will complete 2.5 hours of training and will deliver the programme to students. Primary outcomes of body image and psychological wellbeing, and secondary outcomes of broader body image risk and protective factors will be assessed at three time points (pre, post, two-month follow up). Mediators, (i.e., active ingredients of interventions, e.g., self-compassion) and moderators (i.e., factors that change the strength of effects, e.g., implementation quality) will also be explored to understand how and for whom the intervention works best.
In addition to examining effectiveness, best practice guidelines in school-based research increasingly emphasise the importance of conducting implementation evaluations to assess how well programmes are delivered in schools and if programmes are delivered as intended (49–51). Implementation evaluations are essential for providing insights into factors that may lead to a programme’s success or failure (49). They can also inform efforts to guide sustainable delivery of programmes in schools. Thus, a mixed methods evaluation of implementation quality will be conducted to understand ‘why’ programme outcomes were observed and to inform efforts to optimise programme delivery in schools in the future. Aligning with previous studies (51,52), the quality of implementation of BodyKind in schools will be assessed across four key implementation dimensions: (i) dosage, (ii) adherence, (iii) quality of delivery, and (iv) participant responsiveness.
This study will be the first to implement a cRCT design and implementation evaluation to examine BodyKind – an innovative, gender-inclusive, culturally sensitive programme designed to improve adolescents’ body image and psychological wellbeing. This research is anticipated to provide novel contributions to school-based body image intervention work.
We hypothesise that 1.) Compared to participants in the waitlist control, participants who receive the BodyKind programme will experience statistically significant increases in a.) body appreciation, psychological wellbeing, self-compassion and compassion for others and other’s bodies, social justice motivations and b.) significant decreases in body dissatisfaction and body ideal internalisation from pre- to post-intervention. 2.) Changes will be maintained in intervention groups at a 2-month follow up. 3.) Changes in body appreciation and body dissatisfaction will be mediated by self-compassion, compassion for others and body ideal internalisation. We make no a-priori assumptions about the directionality of mediation effects. 4.) Changes in body appreciation, body dissatisfaction and psychological wellbeing will be moderated by appearance-related social media use, appearance teasing, gender, baseline body appreciation, body dissatisfaction, psychological wellbeing and implementation quality. We make no a-priori assumptions about the directionality of moderation effects.
A mixed methods evaluation (non-directional) will be conducted to determine schools’ quality of implementation of BodyKind across key implementation dimensions. We expect that the programme 5.) will be considered acceptable and feasible by adolescents and teachers, 6.) can be implemented with high fidelity by teachers and that 7.) implementation quality may vary across schools and this may impact intervention effectiveness.