Real-world effectiveness of a German school-based intervention for primary prevention of anorexia nervosa in preadolescent girls
Introduction
Anorexia nervosa (‘AN’) is one of the most serious psychiatric disorders in girls and young women. The Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) includes four criteria for diagnosing AN (see Table 1). Because it is difficult to treat (Steinhausen, 2002) and because of its high mortality rate (> 15%; Zipfel et al., 2000), the disease has gained much attention from the public and from the scientific community. AN's prevalence is estimated at 0.5 to 3.7%, with a peak of incidence at age 15 (Hoek and van Hoeken, 2003, Bulik et al., 2006). Several of AN's symptoms are considerably more common (Grilo, 2006), which are known as sub-clinical expressions of AN. In view of this, groups around the world have spent decades developing prevention programs to prevent the onset and consequences of AN and other eating disorders (for review, see Levine and Smolak, 2006).
According to the standards of the Society of Prevention Research (‘SPR’), a successful prevention approach includes the demonstration of efficacy (level 1) as well as the probation in the field under real-world conditions (level 2 ‘effectiveness’). ‘Real-world conditions’ mean regular conditions in everyday life without the motivational character of a new program introduced for the first time. Furthermore, an appropriate dissemination is necessary to secure sustainability (level 3 ‘broad dissemination’; Flay et al., 2005).
Most of the existing prevention programs do not meet all of the standards, including level 2 and 3. For this reason, in 2003, our institution began cooperating with the Thuringian Ministry of Education (‘TME’) to develop the program called ‘Primary prevention of anorexia nervosa in preadolescent girls’ (‘PriMa’). Our program focuses exclusively on AN, because it occurs earlier (peak of incidence: 15 years) than bulimia nervosa and binge-eating disorder (peak of incidence: 18 years; Grilo, 2006). In 2004 and 2005, we conducted a pilot study to evaluate the process and impact of PriMa (level-1 evaluation; n = 1006 girls; mean age = 12 years; Berger, 2008). This study showed significant improvements in pre–post measurements and pre–follow-up measurement on body self esteem, eating behavior, and knowledge.
Furthermore, we paired with the Heidelberg Prevention Center (www.h-p-z.de; level-3-evaluation; see Berger et al., 2008) to create appropriate distribution structures. Two well-known meta-analyses (Stice and Shaw, 2004, Stice et al., 2007) have summarized the effects of over 80 international programs for the prevention of eating disorders. The authors clearly identify factors that successful programs exhibit:
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interactive (vs. didactic),
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selective, for risk groups (vs. universal),
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multisession (vs. single-session),
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gender specific, offered only to females (vs. co-educative),
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offered to participants over age 15 (vs. younger participants), and
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delivered by professionals (vs. endogenous providers like teachers).
Because of the early peak of incidence of AN, we decided to focus PriMa on 6th-grade girls with a mean age of 12 years. According to most of the programs, PriMa is geared to the WHO-recommended ‘Setting Approach’ (Stewart-Brown, 2006), realizing the program in schools. We focused primarily on girls because adolescent girls and young women are 10-times more likely to exhibit incidents of AN (Grilo, 2006). We adopted a universal prevention program to avoid labeling the participating girls who were already suffering from (sub-clinical) eating disorders or showing specific risk factors. Other universal prevention programs were very effective (Becker et al., 2005, Raich et al., 2009) and primary prevention by definition includes this universal character. Furthermore, our cooperation partners insisted using teachers to implement the project rather than independent professionals on the theory that teachers would improve the program's sustainability.
Existing prevention programs concerning eating disorders focused on decreasing risk factors (e.g. weight concerns, negative body image, dieting, and low social support; Jacobi et al., 2004) and strengthening protective factors (e.g. body self esteem, and knowledge). The present study aims to follow this primary preventive approach (Caplan, 1964) to reduce the occurrence of AN (see Table 2). Furthermore we intend to replicate the results of the pilot study concerning the effects of the PriMa program under real-world conditions (level 2; Berger et al., 2008). In this context, the focused research question is whether the primary preventive intervention program, PriMa, is able to significantly improve the primary outcomes eating behavior, body self-esteem, and AN-related knowledge in comparison to a control group?
Section snippets
Study design and subjects
We designed a controlled trial with (post-hoc) parallel group assignment using pre-post-design, supplemented by a follow-up-measurement after about three months. Before starting the program, we first obtained the consents of the parents, the supervisor of the TME, and the ethics committee of the Jena University Hospital. Our close cooperation with TME required several compromises because TME was focused on the practical effects of the program rather than the underlying research project. Because
Patient characteristics
The demographic characteristics of the girls (IG vs. CG) can be seen in Table 3. IG and CG did not differ significantly, except for ‘age’ (t(885) = 2.66, p = .01). However, this age difference (12.01 years vs. 11.95 years) has a low substantive importance with an effect of d = 0.1 (mean difference about 22 days). Potential distortions through hierarchical effects (individuals in grades in schools) could be ruled out, because the ICC determined from the data is 0.02 (Raudenbush and Bryk, 2002).
793 girls
Discussion
The pre–post control group study described above aimed to verify the effectiveness of PriMa against AN for girls attending the 6th grade that are an average of 12 years old. According to Table 4, we found that values for all variables in the IG developed in accordance with the hypotheses. Compared to the CG, a significant intervention effect could be found only for the knowledge at post as well as follow-up measurement. The body self esteem improved significantly only in the short term
Conclusion
Taking into account the positive results of the pilot study (Level-1, including process evaluation) and the successful implementation of the program in cooperation with the TME and the Heidelberg Prevention Center (www.h-p-z.de), PriMa is a girl-specific, school-based primary preventative method, and is therefore a low-threshold and socially fair intervention. With relatively little effort (9-hour project teaching) and low costs, the program is able to increase AN-specific knowledge and to
Conflict of interest statement
None.
Acknowledgments
We thank the financial support by the Federal Ministry for Education and Research (BMBF: Project no. 01EL0602, term 2006–2009).
Furthermore we thank our practice partner Thuringian Ministry of Education, especially Jutta Beinersdorf and Margit Luedecke for the didactic counseling and competent application of teacher trainings and all the girls for patiently filling out the questionnaires.
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Implementation of the school-based prevention programs PriMa and Torera for eating disorders: A long-term qualitative analysis of barriers and facilitators
2017, Mental Health and PreventionCitation Excerpt :Using teaching manuals, trained teachers or school social workers delivered the programs in nine 45-min to 90-min sessions, choosing either a project week or a nine-weeks program. The program evaluation started in 2004, following the Society of Prevention Research (SPR) standards for efficacy and effectiveness trials (Adametz et al., 2017; Berger, Joseph, Sowa, & Strauss, 2007; Berger, Sowa, Bormann, Brix, & Strauss, 2008, Berger, Ziegler, et al., 2008; Berger et al., 2011; Gerhard, 2006; Wick et al., 2011). The results showed a positive intervention impact on strengthening body self-esteem in the long-term.
Long-term effectiveness of a school-based primary prevention program for anorexia nervosa: A 7-to 8-year follow-up
2017, Eating BehaviorsCitation Excerpt :Moreover, this strategy allows for drawing conclusions about whether a primary prevention program is able to prevent the growth of risk factors as well as the onset of first symptomatology. The sample was recruited from a cohort of 1508 females who attended the former project of the short-term evaluation of PriMa during the period of 2006–2009 (Wick et al., 2011) and did not take part in any other prevention program. Between 2007 and 2008, students at Thuringian schools participated either as part of an intervention group or as part of a control group.
The MABIC project: An effectiveness trial for reducing risk factors for eating disorders
2016, Behaviour Research and TherapyCitation Excerpt :Therefore, developing appropriate attitudes and knowledge in relation to eating disorders among teachers and other community providers through training programs is an essential component in the effectiveness of prevention programs. To our knowledge, only three programs assessed with effectiveness trials, in addition to our own, have developed training programs aimed at teachers and other community providers that equip them to implement prevention programs in this field (Stice et al., 2009; Warschburger et al., 2011; Wick C. et al., 2011). In particular, our training program includes all the elements identified by teachers as necessary for involvement in the administration of such interventions (Neumark-Sztainer, Story, & Coller, 1999; Smolak et al., 2001): (1) in order to increase their motivation, information on the need to carry out this type of intervention was included when the training began: (2) updated information on the issues to be addressed in the program was incorporated; (3) participation was voluntary and intervention was implemented only by motivated community providers; (4) community providers had the support of their management teams and the relevant training was officially accredited; (5) useful materials for implementing the intervention were provided, such as the program manual, the video-model and informational documents about the most relevant content and techniques; and finally, (6) we maintained constant supervision so as to be able to deal with any questions or problems arising and help them feel supported.
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