188.8.131.52 The Start: Trinity University Sorority Body Image Program
The sorority project began in 2001, when Becker and an undergraduate student decided to attempt to replicate Stice et al.’s early work. Consistent with CPR, the decision to approach sororities came from the student, who was a sorority member. As an insider, the student also played a critical role in obtaining the sororities’ cooperation. In this pilot study, Becker, Jilka and Polvere (2002)
randomly assigned 24 sorority members with body image concerns to either two 2-hour sessions of DBI or a media advocacy (MA) intervention. One aim of the study was to tease apart the content of DBI from its theoretically dissonance-producing nature. Thus, MA content was similar to that of DBI, but replaced dissonance activities (e.g., role plays) with videos targeting the role of the media in maintaining the thin-ideal. Becker and two sorority research assistants (RAs) led the groups. Compared to MA, the DBI significantly decreased thin-ideal internalization and body dissatisfaction at 1-month. Both interventions also significantly reduced dietary restraint, eating pathology, and body dissatisfaction.
It is important to highlight that Becker et al. (2002)
began working with sororities not because of a-priori
beliefs about sororities increasing eating pathology, but rather because their organizational structure and community values (e.g., service) made them valuable partners. Although many believe that sorority members are at increased risk for EDs, existing data are equivocal in comparisons of sorority members with other collegiate populations (Allison & Park, 2004
; Cashel, Cunningham, Landeros, Cokley, & Muhammad, 2003
). The rationale for partnering is important because communities may be more likely to partner with researchers when the underlying rationale is empowerment and respect (i.e., your values and community structure empower you to make a difference) rather than blame (e.g., sororities contribute to EDs – or – community clinicians are unwilling to take time to read research).
At the end of the pilot study, Becker and the RAs held a voluntary focus group with study participants to solicit feedback about their experience. Participants requested that the program be expanded and agreed to communicate their interest to their elected leaders. The following fall, Becker and a new sorority RA met with elected officers. During this meeting, results from the first study were presented and a second study was collectively designed. Becker agreed to insure that RAs were sorority members, so that community members benefited academically from the project. One advantage of this approach was that sorority RAs understood the priorities, values, and governance structure of the community. Thus, study logistics were designed to avoid conflicts with the community. Also, as insiders in the community, RA’s often could informally and quickly negotiate solutions around logistical problems.
In the second study, 161 members were randomly assigned to DBI, MA, or waitlist (Becker, Smith & Ciao, 2005
). Becker and sorority RAs facilitated all groups. Results indicated that, compared to controls, both DBI and MA produced greater reductions in dieting, body dissatisfaction, and ED symptoms at one-month follow-up. Only DBI, however, produced significantly greater reductions in thin-ideal internalization relative to controls. DBI did not produce significantly larger effects relative to MA, and results supported the use of both interventions with lower- and higher-risk members.
During the second study, the research team held focus groups with participants who had completed their follow-ups. These community members suggested that, as a next step, the “sorority body image program” (SBIP) should be made mandatory for new members. On this basis, a preliminary meeting was held with officers, who endorsed this plan. Next, the research team, which largely consisted of community members, used insider knowledge to design a specific proposal for the sororities, which was subsequently approved after problem solving a few concerns with officers. Key factors in achieving approval were a) grass roots initiative from community members, b) study co-designed with the researcher and community members, c) increasing trust of the researcher who was now viewed as a community ally, d) ongoing emphasis on empowerment (e.g., “As the largest body of organized women on this campus, you have the power to create change,”) and e) the researcher’s willingness to negotiate design and logistical issues with community leaders.
In the fall of 2003, the sororities made plans to incorporate the SBIP into new member orientation. Because community members wanted to continue to mix members from different sororities in the small groups that comprised the interventions, they agreed to coordinate their orientation schedules so that all new members could attend the program simultaneously. This is an example of the effects of CPR. Because the need to run members simultaneously arose from a grass roots request, leaders were willing to make substantial changes to a major community event after a member (i.e., sorority RA) stated this was necessary. It is unlikely this change would have occurred using traditional approaches. Also, because officers wanted the program run on a semi-mandatory basis (i.e., participation required unless granted an excused absence), we conceptually distinguished between the study and the program so that members could attend the program and opt out of the study. Finally, officers requested that the waitlist control be dropped because this was incompatible with mandatory attendance. Thus, although a waitlist control was ideal from a research perspective, we eliminated it to respect community goals.
Because the research team lacked sufficient clinical providers, a major component of the third study was the use of trained peer-leaders. Sorority peer-leaders who had previously participated in the first or second study underwent nine hours of experiential training (see Becker, Ciao, & Smith, 2008
; Becker & Stice, 2008
for details). All decisions regarding use of peer-leaders, training schedule, training method, recruitment methods, and gifts to thank peer-leaders were generated collaboratively by Becker and community members. The use of peer-leaders conveniently coincided with another key sorority value, leadership. Interestingly, likely due to the use of CPR, the SBIP had developed into a program that matched the four key values of sorority life: service, leadership, scholarship and sisterhood. To further build on this, intervention manuals were modified in an iterative process aimed at tailoring the DBI to the community’s language and values. Given that prior to this work Becker had no experience with sororities, learning the community values and language was another CPR element.
The third study (Becker, Smith, Ciao, 2006
) evaluated the effectiveness of DBI and MA when administered by peer-leaders on a semi-mandatory basis to new members (N = 90). New members were randomized to MA or DBI. Participants in DBI showed significantly greater reductions in thin-ideal internalization, body dissatisfaction, and dieting compared to MA at 8-month follow-up; both interventions significantly reduced ED symptoms.
After completion of the new members study, the research team met with community officers to review the process and preliminary results. A consensus agreement was reached to run the program and an associated study annually. Key elements of this agreement included a) continued staffing by sorority RAs so that members of the community benefitted academically, b) annual review of results by and a study proposal for newly elected officers so that they could have input into the research design for the next year, c) annual solicitation of feedback from participants and peer-leaders, d) ongoing support from the research team in helping the community obtain credit for their work on this project so as to improve their public relations image, e) support from the research team whenever a member was identified as having an ED and when the community wanted to engage in related activities that would not generate data (e.g., holding a body image event), and f) giving priority to the community in sustaining their program before starting other programs as a way of recognizing their contributions.
To date, sorority members have conservatively contributed over 12,000 unpaid hours to the study and implementation of DBIs, and a follow-up new-members study replicated the viability of using peer-leaders to deliver DBIs (Becker, Bull, Schaumberg, Cauble & Franco, 2008
). In addition, results from a study of three cohorts of peer-leaders suggest that peer-leaders who run the groups show greater reductions in risk factors (Becker, Bull, Smith & Ciao, 2008
) than participants who just complete the program. Finally, the SBIP has led to the development of a pilot program in athletics, which also was developed using CPR. This co-designed study examines the relative effectiveness of DBIs versus the healthy weight intervention designed by Stice and associates when interventions are administered by peer-leaders on a semi-mandatory basis in athletic teams. Consistent with CPR goals, we modified the interventions to address the specific concerns of female athletes. All study decisions, including manual modifications, were collaboratively made by Becker, a former collegiate Trinity athlete, and the head athletic trainer, in consultation with the director of athletics and coaches. This expansion provides evidence that the CPR strategies that worked well with sororities appear to generalize to a quite different community (e.g., athletics).
184.108.40.206 Expanded Distribution: Tri Delta Reflections Program
In 2005 the Delta Delta Delta Fraternity (i.e., Tri Delta sorority) learned of the SBIP via its alumnae network. During a series of phone meetings, CPR methods were used to explore how an organization such as Tri Delta, which has approximately 13,500 collegiate members and 136 chapters in North America, could implement the SBIP. Examination of existing programs in the Greek community showed that no template existed for large scale distribution of a program like DBI. Becker identified two non-negotiable factors: the program could not be watered down and data had to be collected to determine if the program continued to work under the new circumstances. All other features (training procedure, where, when, how, who) were open for discussion and decided collectively.
We should note that Tri Delta receives multiple programming proposals from outsiders on a continual basis, and almost all of these proposals are rejected. Key factors in Tri Delta’s decision to pilot test the SBIP included a) program was identified by a community member (i.e., alumna) who used her insider knowledge regarding the community’s commitment to addressing key women’s issues b) clear evidence from the Trinity project that the researcher would respect their community and understood their values, and c) quality data supporting both efficacy and effectiveness (drawn from both Stice et al. and Becker et al.). Tri Delta also appreciated that its staff’s opinions and knowledge of their community were respected during early discussions. These factors highlight the important role that both CPR and classic efficacy/effectiveness research played in the success of this dissemination effort.
The first pilot study consisted of sending Becker to 2 chapters to conduct 8 hours of peer-leader training with members who had no prior experience with the program; letting the peer-leaders run the program with limited on-campus faculty/staff supervision; and assessing outcome and adherence. Because this research was not grant funded, both parties (i.e., the community and researcher) invested their own resources to move the project forward. For instance, Tri Delta underwrote required expenses for the program (travel and materials costs). Becker contributed her time (i.e., trainings, phone meetings, consultation, program planning, IRB applications, supervision of undergraduates at the data sites etc.). It is not uncommon for CPR projects to require participants to pool resources and move forward without external research grant support.
Results from this initial two campus open pilot study (Becker, Bull et al., 2006
) indicated that although the SBIP produced positive results, effect sizes were smaller than in Becker et al. (2006)
and adherence was reduced. Thus, results were promising, but suggested that a different model was needed. Brainstorming sessions yielded a plan to expand the program to five chapters by training and deploying Tri Delta BA-level field consultants (FCs) to run groups, train peer-co-leaders, and oversee implementation. Two chapters were chosen as data sites to test outcome. A junior researcher also was recruited to help oversee data collection at one site. This researcher was assured that she would have the right to be first author on papers based on data collected from that site. Five month results from this site, pre-post results from the second data site, and review of audiotapes supported the viability of the FC distribution model (Perez et al., 2007
). The program also had the benefit of helping Perez launch several related projects.
On the basis of the second pilot, Tri Delta decided to begin the project in earnest. Over the next year, Becker, Stice, Oxford University Press (OUP), and Tri Delta leaders worked together to address copyright issues and create a manual that could be widely distributed (note: much of the SBIP content had recently been published by OUP as The Body Project, but the manual by Stice and Presnell 
did not meet the needs of this community). Tri Delta assumed all financial risk, with leaders first agreeing to raise $100,000 for this effort, and subsequently deciding to simply underwrite publishing of sufficient materials for 20,000 collegiate women to speed up the process. Several other universities and national sororities also began pilot testing, and Tri Delta committed to making SBIP available to all sorority members nationwide, not just its members. Tri Delta also decided to use this project to increase utilization of other variants of DBIs (e.g., The Body Project), and expanded the range of staff involved by including public relations, marketing, and licensing staff in discussions aimed at resolving logistical issues related to distribution, marketing, and quality control. Ongoing use of CPR resulted in the name being changed to Reflections: Body Image Program. CPR also was used to problem solve training issues and strategies for sharing the program with universities and other sororities. Recently, Tri Delta successfully launched both a week long advocacy effort aimed at building grass roots interest (Fat Talk Free Week
) in DBI, and also Reflections: Body Image Academy. Designed using CPR, the academy provides 18 hours of training to individuals interested in bringing Reflections to either their chapter or campus, and includes both student and professional (i.e., counselors, Greek advisors, Student Affairs staff, community ED therapists and researchers) tracks. Finally, additional researchers have been recruited to add data sites for ongoing evaluation, perform quality control checks, and to further Tri Delta’s mission to enhance scholarship among its members, undergraduate and graduate students generally, and junior faculty. One ongoing challenge is balancing momentum with maintenance of quality.