Examining Teacher Concerns and Anxiety on the Implementation of a Universal Body Image Program
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1. Introduction
The dissemination and implementation of evidence-based interventions recommends assessing provider concerns and barriers to implementation [1]. Universal mental health prevention programs developed for school settings have the ability to reach large numbers of youth in a cost-effective and scalable manner [2]. Within the last several decades, there has been an increase in the development of preventive evidence-based programs aimed at reducing eating disorder symptoms and body image concerns among children and adolescents [3]. Many of these body image interventions occur in classroom-based settings and have been shown to produce reductions in body dissatisfaction [4], with some demonstrating sustained improvement in body image concerns through follow-up [5]. Importantly, adopted and widely distributed evidence-based prevention programs tend to vary in quality of program implementation and can, at times, fail when implemented in real-world settings [6]. Although there is research addressing the effectiveness of body image prevention programs, there is a lack of attention to potential barriers precluding implementation of these interventions in school settings. Understanding and identifying potential barriers to the implementation of prevention programs, including teacher-led body image prevention programs, is necessary to increasing the use and effectiveness of these programs.
The majority of teacher-implemented school-based programs addressing body image concerns focus on adolescents, with relatively fewer available for pre-adolescent children. In a recent systematic review conducted by Kusina and Exline, researchers examined 34 classroom-based intervention programs designed to reduce body dissatisfaction and promote positive body image among youth aged 12–18 [7]. In their review, researchers identified notable variations among these programs, including differences in intervention methods, interventionists, and their impact on outcomes. Kusina and Exline reported that universal programs, as compared to alternate approaches, result in increased body image [7] in adolescents consistent with previous research [4]. In addition, program outcomes did not differ across studies that used researchers versus teachers as the interventionist. However, there is one study among adolescents that found significant improvements in body image when teachers led the program as opposed to research staff [2]. In contrast to adolescents, there is a paucity of research on school-based body image programs for pre-adolescent children. Existing research finds that school-based body image programs yield body image improvements post-intervention [8,9,10,11], at times yielding more benefits for girls than boys [8] and with differential maintenance of outcomes at follow-up [8,12]. Similar to findings for adolescents, teacher-led programs are effective in increasing body image and self-esteem among 5-to-8-year-old children [13] and decreasing internalization of thin ideals and eating disorder behaviors across 11-to-12-year-old children, with small to medium effect sizes [12]. Collectively, research across both childhood and adolescence suggests teachers can be effective at implementing body image programs in schools. This is important for dissemination of prevention programs as the use of teachers relative to researchers and mental health professionals is more cost-effective and makes it possible to disseminate at larger scale [2,14].
To date, there has been no research conducted on potential barriers to the implementation of teacher-led body image programs. However, school-based prevention programs for other psychological issues, such as bullying and teasing, physical activity, and violence, have explored the influence of teacher characteristics on program implementation. For example, in the Olweus Bullying Prevention Program, teachers are key in implementation of the program [15]. Empirical work has explored teacher characteristics such as demographics and self-efficacy, teacher perceptions of bullying as an issue in schools, teacher experiences with bullying, and school climate, as influencing the number of activities from the Olweus program implemented in the classroom [15]. Higher teacher self-efficacy, more frequent teacher experiences with bullying, and a greater perceived need for the program predicted higher numbers of programmatic activities implemented and greater teacher involvement in the curriculum overall [15]. In a review of school-based physical activity programs, higher teacher self-efficacy predicted implementation of a physical activity program in the classroom [16]. Further, the personal physical activity habits of teachers predicted teacher self-efficacy, which, in turn, predicted if the program was implemented in the classroom [16]. The implementation evaluation of a mental and social well-being promotion program found teacher characteristics such as teacher motivation was associated with program implementation and the overcoming of barriers and challenges that occur with program implementation [17]. In a teacher-led school-based violence prevention program, teacher self-efficacy predicted initial program implementation, and increases in self-efficacy across time predicted increases in program implementation across time as well [18]. Finally, in a review of 500 studies that implemented promotion and prevention programs for youths across physical health, mental health, academic, and development categories, the interventionist or provider characteristics that were consistently related to implementation were the recognition of a need for the program, the belief that the program would be beneficial, self-efficacy, and having the required skills to implement the program [1]. Collectively, these studies highlight the impact of interventionist characteristics in implementation and, specifically, self-efficacy consistently emerged as associated with program implementation across diverse school-based prevention programs.
Although there is no research on implementation, needs assessment surveys have been conducted that elucidate some teacher concerns related to body image. For example, early childhood and elementary school teachers reported wanting body image resources for promoting positive body image in children, how to deal with external influences such as messages from the media, and early detection and intervention strategies [13,19]. Although limited, this empirical work suggests teachers perceive a need, but have a lack of training for handling the issues that arise and promoting a positive body image in the classroom. This potentially suggests that teacher self-efficacy and teacher concerns may play a role in the implementation of a body image program.
The current study aimed to address the gap in the literature related to teacher characteristics and perceptions related to implementing a school-based body image program. The current study explored the relationships between teacher characteristics such as gender, years teaching, self-efficacy, teacher concerns with implementing a universal school-based body image program, and the number of weeks the program lessons were implemented. Consistent with previous research, we hypothesized that higher levels of self-efficacy and more years in teaching would be associated with fewer teacher concerns and more program lessons implemented (i.e., more program content covered in class). Exploratory analyses were conducted to examine if teacher’s own body esteem, dieting behaviors, or other weight control behaviors were associated with teacher concerns or number of program lessons implemented. Previous work has found that both parents and educators are concerned with their own body image concerns influencing the children’s body image [13,19]. Thus, we hypothesized that higher teacher body esteem scores would be related with fewer teacher concerns and more program implementation; conversely, we hypothesized that greater dieting or other weight control behaviors would be associated with a greater number of teaching concerns and less program implementation.
4. Discussion
The current study aimed to address a gap in the literature by examining if teacher characteristics or perceptions were related to concerns teaching a positive body image program or the extent of program implementation. The goal was to illuminate potential barriers of implementation of universal school-based body image programs to facilitate program uptake and scalability. Across the 259 teachers in the study, there were some concerns reported with teaching a body image program to 4th and 5th graders; however, overall concern was relatively low. This may be due to sample characteristics. Teachers who enrolled in this study were those willing to participate in a randomized controlled trial where they would implement a body image program. This potentially creates a selection bias of teachers less hesitant to implement the program. An online survey of teachers, regardless of program implementation, may provide a greater diversity and intensity of concerns and may be a good avenue for future research. Regardless, over half of the teachers in the study reported some concerns with saying the wrong things, the extent to which their own body dissatisfaction may make them uncomfortable teaching the program, and inexperience teaching a body image program. Teachers’ written feedback reinforced concerns related to how their own body image could impact the program and also highlighted concerns with parents’ negative reactions to the program.
Teacher body esteem was significantly associated with teacher concerns, such that higher body esteem scores were associated with fewer teacher concerns. This aligns with the teacher concerns expressed regarding teaching a body image program. Collectively, these findings suggest teacher manuals (i.e., facilitator guides) should incorporate a section on the impact of teacher body dissatisfaction on teaching a body image program. Providing information on important considerations and potential areas in the curriculum where a teacher’s body dissatisfaction may interfere may assuage concerns. For example, when assisting students in creating positive body affirmations, teachers can prepare example affirmations ahead of time. Similarly, when preparing for the lesson on combating body talk, diverse strategies may be outlined ahead of time. The teacher manual may also include sample statements and strategies to assist teachers. Further, future research should examine if teacher body esteem impacts the effectiveness of teaching a body image program. This may potentially help pacify potential anxiety and concerns or identify specific areas to include within teacher manuals.
Although the Amazing Me curriculum is designed to not require any formal teacher training, online videos can be provided to teachers that address common concerns and pitfalls when teaching a body image program. This video can discuss common concerns and strategies and solutions for alleviating concerns. For other school-based body image programs that include teacher training, incorporating a section on anxiety and concerns and how to handle these, can be beneficial. Allowing teachers the space to voice their anxieties and concerns, and brainstorm ways to resolve these concerns may increase self-efficacy, uptake, and the number of activities implemented within the program.
Teacher self-efficacy significantly predicted the number of weeks the teacher implemented the body image program. Higher self-efficacy was related with greater implementation. This is consistent with the existing literature. Research from school-based programs on psychological issues such as bullying and teasing, physical activity, and violence have all found teacher self-efficacy to predict program implementation [15,16,17,18]. It may be beneficial for school-based psychological programs to include a motivational interviewing approach within the training of teachers. Motivational interviewing is an evidence-based approach that explores and resolves ambivalence or anxiety/concerns, and focuses on motivational processes that facilitate behavior change [24]. This approach can increase teacher self-efficacy, increase motivation, highlight the importance and need of the program, and potentially increase program implementation. Indeed, the peer-reviewed journal Prevention Science, has a special issue dedicated to “Optimizing the Implementation and Effectiveness of Preventive Interventions through Motivational Interviewing”, which includes a discussion of core aspects of motivational interviewing, and how motivational interviewing incorporates into existing dissemination and implementation frameworks [25]. Further, the special issue includes empirical work on the Beliefs and Attitudes for Successful Implementation in Schools for Teachers (BASIS-T) program, which is a motivational interviewing session given to teachers in a group format immediately before and after teacher training on an evidence-based prevention program on teachers [26]. The use of this program increased teacher motivation and self-efficacy to increase program implementation.
It is important to note that gender was associated with teaching concerns but not program implementation. Male teachers reported more concerns with teaching a body image program than female teachers. Specifically, male teachers expressed significantly more worry about saying the wrong things than female teachers. Unfortunately, it is unclear if teaching concerns qualitatively differed across the genders as no male teachers provided written feedback. In addition, there were only nine male teachers in the sample, limiting the generalizability of the findings. Future research should consider including a larger sample size of diverse gender identities to explore teaching concerns and implementation of a body image program.
Another noteworthy consideration is the fact that the Amazing Me program includes appearance- and weight-related bullying and teasing, yet teachers reported no concerns related to teaching bullying and teasing prevention. This may be because all 50 states address bullying and teasing in schools, with some states requiring anti-bullying prevention programs [27]. Thus, teachers may have experience and confidence in implementing anti-bullying activities.
Aside from the strengths and limitations of the current study mentioned above, the current study has a couple more notable strengths and limitations. The sample was large and geographically diverse representing over 30 states across the United States and schools across various socioeconomic statuses. However, data collection occurred during the COVID-19 pandemic, which presented unprecedented stressors for teachers, which could have influenced the recruitment, retention, and results of the study. The online survey administered to teachers at baseline was face valid, and teachers could easily determine why the authors would be asking about teacher dieting, weight control behaviors, body esteem, and teaching self-efficacy, prior to the potential implementation of the body image program. It is unclear to the extent that demand characteristics could have played a role in teacher responses. Finally, the implementation variable consisted of the number of weeks a teacher implemented the program, potentially limiting understanding of the ‘dose effect’ of program implementation. It is possible that teachers implemented one, two, or three activities per week and this is not captured in the data.
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