The intervention will be delivered by Health and Physical Education (HPE) teachers of Year 9 boys in secondary school, during weekly face-to-face HPE classes at participants’ schools. All teachers will receive a facilitator workbook (specifically designed for this program) with structured activities and explanations for how to deliver the program. Resources to support delivery of activities are also provided. Attendance of participants will be monitored using attendance sheets for each lesson. Adherence to session content will be monitored using a self-report checklist completed by the teacher following each lesson.
Participants will be allocated to the intervention or control group through cluster randomisation, at the school level. Intervention participants will complete questionnaires at baseline, receive the four-lesson program, delivered once-per week, and then complete 1 week post-intervention, and follow-up (2 months after post-test) self-report questionnaires. Participants in the control condition will complete questionnaires at parallel timeframes, but will not receive the intervention. Comparison of change over time between the intervention and control groups will inform evaluation of program efficacy. We hypothesise that, relative to the control group, the intervention group will show improved scores on primary outcomes (body image, attitudes towards APES, intentions to use APES, use of supplements) and secondary outcomes (body talk, social norms for APES, body talk, internalisation of appearance ideals).
Literature review
Body dissatisfaction and related psychological disorders, including eating disorders, are now widely recognised as issues for boys and men [
3]. While prevention of body dissatisfaction and eating disorders among women and girls has made a great deal of progress since research on this topic first began in the 1980’s, little evidence exists regarding appropriate approaches and effective programs for boys and men. Several high-quality reviews and meta-analyses of body dissatisfaction and eating disorder programs exist [
4‐
7]; however, within this literature, very few prevention programs have been designed specifically for boys.
The theoretical basis for prevention programs for males varies. Dissonance-based approaches are popular and have produced notable improvements in body dissatisfaction [
8‐
10] and eating disorder symptoms [
8,
9], with small-to-large effect sizes (
d = 0.30–1.00) among adult men. Programs that have improved both eating disorder symptoms and body image in boys include a media literacy program [
11], and a mixed-approach program including developmental, psychoeducational, body acceptance, and media literacy content [
12]. However, findings appear less consistent in boys than in girls. For example, while an early trial of Media Smart [
11] demonstrated improvements in body image and eating disorder symptoms, a later trial of the program [
13] demonstrated significant reductions in body dissatisfaction among boys from pre-post, but found no change for weight and shape concern or dietary restraint. Adding to the complexity of research in this area, it is also common for authors to use combined approaches, using two or more strategies such as media literacy and a focus on the influence of peers [
14‐
16], making it unclear as to which specific approaches and/or combinations may produce the most favourable outcomes.
In order to address the lack of knowledge about the most promising approaches and programs for boys, it may be necessary, at least initially, to design single-gender programs specifically for boys. Although co-educational universal body image and eating disorder programs are more common (e.g. [
10,
14,
17,
18]) than programs specifically for boys or men, some programs have been designed for, and delivered to, male-only audiences [
8,
9,
19‐
21], with some success, particularly among adult men. In previous body image research in a co-educational learning environment, either the boys or the girls improve; improvements are rarely observed for both genders [
7]. A focus just on boys is therefore suggested in order to determine exactly what works for males, even though in the longer term, co-educational programs are more practical for the majority of school and university environments, and are important in achieving broad societal change, as opposite-sex peers play an important role in reinforcing and perpetuating sociocultural appearance ideals and pressures more broadly [
22,
23]. In addition to these considerations, our other work has found that those who have higher levels of body dissatisfaction are more likely to indicate that they would prefer a single-sex environment for body image intervention programs [
7]. Similarly, in the clinical space, some researchers suggest that male-only groups will allow boys and men to voice their concerns and be more vulnerable than in environments where women are present, and that the impact of realising that body concerns are normal among men is valuable in improving outcomes for men [
24].
In addition to delivery environment, it is also important to examine the impact of the facilitator of intervention programs. Co-educational, and male-focussed programs have typically been delivered by a researcher [
11,
12,
14,
15,
21,
25,
26], with the exception of The Body Project, which is typically peer-delivered [
8‐
10]. At present, it appears that
who delivers the program may be unimportant; no consistently positive or negative outcomes in intervention efficacy according to whether the facilitator was a researcher or a peer, or the gender of the facilitator, are apparent. Teacher-delivered interventions are less common [
17] which may be due to the practicalities of training teachers in the program activities, and body image and eating disorders if they are unfamiliar with current literature.
There is now a well-recognised need to incorporate the perspectives of end-users into the design of intervention programs in order to ensure that what is developed meets their needs. Several prevention programs describe developing materials using collaborations between stakeholders and researchers [
17], focus groups [
14] or submitting activities to the target population for feedback [
8,
9,
19]. This may be particularly important when designing or adapting materials for males, as the literature on the nature and experience of body image and eating disorders in men and boys is limited compared with the same topic for women and girls. Design thinking [
27] and participatory action research [
28] are both structured approaches to developing research that incorporates the views of the intended audience or recipients. We incorporated both of these approaches in the design of the Goodform intervention.
Design thinking gives a structured process for designing a product (or intervention) that takes the needs, attitudes, and feedback of end-users (in our case, end-users are adolescent boys, their teachers, and parents) into consideration [
27,
29]. Design thinking approaches are similar to Community-based Participatory approaches, and involve: 1) considering the needs of end-users, and 2) incorporating the feedback and needs of end-users in an iterative process of product or intervention development to ensure that the end product will be usable and effective.
Preliminary studies
We conducted three studies in the course of developing our intervention. Two were conducted by Masters-level students and are published in student theses [
30,
31], and one was conducted by the research team [
32].
The first study examined parent attitudes towards, and knowledge of, APES and body image [
30]. Participants were parents of boys aged 14–17 (
N = 7) and took part in semi-structured interviews. Some of the main findings that informed the intervention content of Goodform were that parents noted the lack of (but potential benefit from) education about APES within schools, and that this education should include evidence-based information with high source credibility.
The second study was a pilot test of a digital tool and video intended for the first lesson of Goodform [
31]. Participants were 52 boys, with 28 trialling an initial version and 24 trialling a post-feedback optimised version. Generally, the content was acceptable although feedback indicated basic concepts should be explained in more detail. The majority of issues were practical or technical in nature and resulted in improved on-task behaviour (e.g., asking serious questions about the task, and reductions in off-task behaviour such as fidgeting) and engagement following resolution of these issues. Specifically, workbooks for both students and teachers were produced to help guide users through the task, errors in the tool itself were fixed, and content was added to the digital tool to allow for more student exploration of the topic.
The third study was a mixed-methods study which broadly focused on the process of developing a body image prevention program for boys [
32]. This study incorporated feedback and findings from the two studies described above, in addition to feedback from in-depth interviews with boys, and questionnaire feedback from body image experts, with the aim of identifying effective strategies for developing boys’ body image programs. Five themes were identified that would benefit end-users (boys, their parents, and teachers) of body image programs, such as an awareness of social norms for boys, understanding the importance of authority and credibility of information, increasing interactivity of projects, and having a good understanding of classroom practicalities when delivering interventions.