心理師、輔導教師與同儕領導介入在女高中生飲食異常預防方案之應用

Application of Psychologist-led, School Counselor-led, and Peer-led Eating Disorder Prevention Interventions in High School Girls

探究心理師、輔導教師及同儕三種不同介入者，對女高中生進行飲食異常預防方案之成效及差異情形。本研究採準實驗設計並分兩階段進行，首先邀請三所高中參與本研究，以「飲食態度量表－26題版」（Eating Attitude Test-26, EAT-26）21分為切點，從三校兩學年度共1886位高一女生中，篩選出高危險群160位（8.5％），由其中招募到66人參與內含四單元、每單元1.5小時的「飲食異常介入方案」。研究者將此66位有意願參與方案者，分派入「心理師介入組」、「輔導教師介入組」與「同儕介入組」，總計11組實驗小團體，並招募對應控制組共78人，比較實驗組與控制組在EAT-26及身體意象量表之立即與三個月延續成效，與三組成效差異。相較於控制組，不論在立即與延續效果，「心理師介入組」在EAT-26及身體意象量表得分均達顯著差異；「輔導教師介入組」在身體意象量表分數達顯著差異，而「同儕介入組」則未呈現顯著差異；比較三組在身體意象量表之改變成效，「心理師介入組」顯著高於另外兩組，而在EAT-26之輔導成效三組無顯著差異。心理師介入在降低飲食異常危險因子及身體意象均具顯著成效；輔導教師介入可顯著改善青少女對纖體文化之執著；同儕介入則未呈現顯著成效，文末提出本研究之建議與限制。

Most eating disorder intervention programs outside Taiwan are based on quasiexperimental designs. They use school classes or small groups as intervention units and compare short- and long-term effects. Intervention outcomes revealed that, compared with other groups, participants with cognitive dissonance exhibited significantly greater reductions in risk factors for eating disorders and bulimic symptoms (Stice et al., 2006). Although many intervention programs have claimed to be effective, those yielding more significant outcomes have had certain research design features, such as being specially designed for eating disorders, being interactive rather than directive, being multiunit rather than single unit, recruiting mainly female participants older than 15 years, and using interventions conducted by professional counselors (Stice et al., 2007). In Taiwan, the early prevention of eating disorders remains in its infancy, and few studies have focused on prevalence surveys, risk factors, related influencing factors, or sporadic case reports. Current survey results in Taiwan indicate that the prevalence of individuals at a high risk of eating disorders is between 8.6% and 17.5%, and the younger the individual, the higher the prevalence is, highlighting the importance of early prevention. Remarkably few studies have been conducted on interventions to prevent eating disorders in Taiwan; therefore, based on past research findings, the present study explored the effects of on-campus prevention programs for eating disorders. The aim of this study was twofold: (1) to test the effects of three different interveners (i.e., psychologists, school counselors, and peers) using the same intervention program to reduce the risk factors for eating disorders in high-school girls and (2) to compare the effectiveness of the three interventions. Three high schools were recruited to participate in the first stage. We selected groups at high risk of eating disorders among ninth-grade students by using the Eating Attitudes Test 26 (EAT-26). A total of 1886 high-school girls from the three schools were divided into 21 scores using the EAT-26, and 160 high-risk girls (8.5%) were selected. During the second stage, 66 at-risk female students agreed to participate in the experimental group and were assigned to either the psychologist-led group (PCG), school counselor-led group (SCG), or peer-led group (PEG); furthermore, 78 students were recruited for the control group. The experimental group participated in the Prevention Program for Eating Disorders (PPED), a well-tested eating disorder prevention program that involves four 90-minute group sessions. The program mainly allowed participants to criticize the value of ＂skinny is beautiful,＂ establish concepts of correct nutrition and health, acquire skills to respond to pressure related to body image, and enhance their self-confidence. School counselors and peer leaders were required to attend a 6-hour training session to learn how to implement the program. To enable peer leaders to administer the program effectively, a systemic peer-led training program was conducted; thus, with the help of school counselors, experienced group members were able to lead a new group. The effectiveness of the program was evaluated using the EAT-26 and the Body-Image Ideas Questionnaire (BIQ). All participants were asked to complete the EAT-26 and BIQ at the end of the intervention and again at the 3-month follow-up. Compared with the controls, the PCG achieved significantly greater improvement in EAT-26 and BIQ scores for short- and long-term effects; the SCG achieved significantly greater improvement in only BIQ scores for immediate and continuous effects; and the PEG did not exhibit any significant differences in scores. Regarding the effects of the three groups on changes in BIQ scores, the PCG had a significantly greater effect than the other groups did, but no significant difference existed in the effects on changes in EAT-26 scores. Overall, the intervention of the psychologist can significantly reduce the risk factors of eating disorders and improve the positive body image, while the intervention of the school counselor is only effective in promoting a positive body image. The intervention effect of school counselors was not as beneficial as that of psychologists, and a possible reason for this was shared by one school counselor: ＂…there are manuals to follow during the intervention process, but in education and training for professional development, there is not much knowledge about eating disorders and a lack of training on how to lead critical thinking, so more practical leadership experience is required to become proficient.＂ For the PEG intervention, the preventive effect could not be determined. The reason may be related to the younger peer leaders, less training time, fewer leaders in the group, and the special status of participants. Future implementations of the PPED should train older peer leaders, increase their training time, and enhance the training content, as previous research has suggested, by placing greater emphasis on role-playing leadership skills (Stice et al., 2009). This study proposes the following suggestions: initially, off-campus psychologists can provide 4-6 hours of training and supervision to school counselors. After training, school counselors must lead an intervention group to familiarize themselves with the PPED and recruit future PEG leaders. Then, the school can establish and continue to promote the PEG intervention to prevent eating disorders early on campus. Because peer leaders have no experience, this study suggests that groups not exceed six members and receive more than 8 hours of training and supervision. The number of leaders can be increased to three. If this works smoothly, school counselors will not need to invest excessive energy in the long term, and this model will effectively prevent eating disorders in young female students in the long term. In addition, this study differs from past intervention studies on the prevention of eating disorders. The participants not only comprised those who were dissatisfied with their body image but also those at high risk of eating disorders. Although this made the research difficult, it increased the ability to intervene for those in need and made exploring the effect of the program content on preventing eating disorders in young girls possible. This study had the following limitation: the three intervention groups spanned three schools and multiple semesters, and thus, the time of intervention, number of group members, and initial scores of group members may be different due to the above reasons; therefore, the conclusions of this study must be viewed with caution. In summary, the results indicated that with proper planning, schools at all levels can promote various prevention programs for physical and mental health, even on sensitive topics such as eating disorders. Such programs will be highly beneficial for students in terms of facilitating early prevention. Moreover, with appropriate prevention programs and training, school counselors will not only be a critical resource for preventive on-campus interventions but also key promoters of establishing peer-led groups; thus, early preventive interventions can be made sustainable. Such a prevention model based on the advantages of campuses is extremely helpful for harnessing the energy of the school system to promote student health. However, because schools in Taiwan place excessive emphasis on academic performance, the arrangement of long-term activities that fit in with schools' routine work is difficult. Therefore, to continually promote early interventions for young people in schools, a national education policy must be fully planned and implemented.