International training programs on eating disorders for professionals, caregivers, and the general public: A scoping review
© Piat et al. 2015
Received: 7 May 2015
Accepted: 31 July 2015
Published: 14 August 2015
This review identified and synthesized published training programs on eating disorders (ED) (anorexia nervosa or bulimia nervosa) for professionals, natural supporters of people with ED, or the public. A scoping review using the Arksey and O’Malley (2005) framework was conducted. Four data bases were searched, for all years, and manual searches from three additional sources were also conducted. Experts on ED were consulted for validation of the identified studies. A narrative synthesis was performed. A total of 20 evaluation studies from five countries were identified, and reviewed in relation to 14 ED training programs. Characteristics of the training programs, and study characteristics, were highly diverse, as shown on Table 1 which compiles results from the charted data. Evaluations were equally divided between training for healthcare and education professionals (9), and training for families or other carers of people with ED (10). One study evaluated ED training for the general public. We found that training orientation varies with the interests and needs of different trainee groups. While most studies assessed trainee outcomes, future research needs to give greater consideration to patient perspectives, and to the relationship between training and evaluation approaches, improved knowledge, and better care.
This scoping review was conducted to support the development of an evidence-informed training program for primary healthcare providers through the Douglas Eating Disorders Program in Montreal, Canada. The research question was broad: What training programs on eating disorders (ED) are available for professionals, or natural supporters of people with ED? The review aimed to identify, and describe, published training programs that have been both implemented and evaluated. We were interested in identifying training focused on assessment, treatment and support for people with ED, as well as prevention-focused training.
The scoping review methodology is ideal for rapidly mapping a field of research with a view toward identifying gaps in research or practice. Scoping is usually exploratory, according to Davis et al.  The present review used the 6-staged framework for scoping reviews developed by Arksey and O’Malley , which is structured in line with a systematic review: development of the research question, study selection, charting, summarizing and reporting results. We also included a consultation stage with experts in the ED field.
A systematic literature search was conducted using electronic databases, and manual search techniques. Four databases were included: Ovid Medline, Pubmed, Embase, and a keyword search of the Scopus database, using the terms “eating disorders”, “training”, and “primary healthcare”. Date restrictions were not applied, as we were interested in identifying all published training programs on ED. Manual searches for additional studies included: 1) the reference lists of all selected articles; 2) tables of contents for 2009–2014 in the following journals: The International Journal of Eating Disorders; Eating Disorders: The Journal of Prevention and Treatment; European Eating Disorders Review; Eating Disorders; and the Journal of Eating Disorders; and 3) websites for the Academy for Eating Disorders; National Eating Disorder Association (US), and National Eating Disorder Information Canada. Experts on ED were consulted (HS, MI) in order to validate the study selection, and suggest names of other key authors.
Inclusion criteria for the study were: 1) published articles in English or French; 2) all study designs; 3) a trainee group: professionals from any discipline; family members or other caregivers of people with ED; the general public; and 4) a target group: people of any age diagnosed, or at risk for, anorexia nervosa or bulimia nervosa. The exclusion criteria were: 1) non-research studies and books, except for descriptions of ED training programs where an evaluation was published separately; and 2) ED intervention studies.
Data extraction and synthesis
The research team developed a data charting form consisting of three overall categories: reference information on the studies (title, authors, journal, publication year, author disciplines, country); training program details (program name, objective, approach, setting, training description, trainee and target populations); and details of the evaluations: (purpose, methodology, participants, data collection, study results/outcomes, study limitations/contributions, recommendations). The data were charted by two researchers (AP, JS), in conjunction with the project lead (MP). A narrative synthesis of the data was performed. The narrative synthesis is a conceptual and interpretive approach focused on the relevance and contribution of evidence rather than rigidly determined methodological criteria; it is especially appropriate for synthesizing methodologically dissimilar studies [1, 8].
Characteristics of studies in the review
Training program title
Article ID: Author, year, country
Ontario community outreach program for eating disorders
McVey, 2005  (Canada)
Increase community-based practitioners’ knowledge, involvement and level of comfort to treat clients with EDs; to foster linkages among practitioners in and across regions of the province. Based on an evidence-based model of care
Healthcare practitioners; school boards & public health departments
Adults, adolescents, children
Quantitative; pre-post intervention survey
↑ knowledge re ED, body issues; ↑ confidence to treat or teach on ED; better practitioner links
The student body: promoting health at any size
McVey, 2007  (Canada)
A prevention program for elementary school teachers and public health practitioners. The web-based approach made the program accessible both inside and outside school hours
Elementary teachers; public health professionals
Elementary school children
↑ teacher knowledge re dieting & peer influence; high satisfaction w/ online tools & self as role model
The Meal Support Training (MST)
Cairns, 2007  (Canada)
Introduces concept of meal support; helps others understand feelings of youth with disordered eating around meals; provides approaches/strategies for meal support
Parents, caregivers, friends of eating-disordered youth
Children with ED
+ parent ratings on manual & video, especially re patient input. Tools support parental instincts
Maudsley eating disorder collaborative care workshops
Sepulveda, 2008  (UK)
Aims to strengthen knowledge and skills of carers, while reducing the burden of caring for their children with ED. Elements of approach: Skill-based instruction; group format; observation of others’ skills; weekly goals
Family members of people with all forms of ED
Children treated for ED at South London & Maudsley Hospital
Quantitative pre-post design + 3 month follow-up
↓ carer distress and care burden over time; benefits = new skills, exchanging with others
Sepulveda, 2008a  (UK)
Aims to strengthen knowledge and skills of carers, and reduce the emotional burden of caring for their children with ED. Approach includes theory and instruction; demonstration and practice; telephone-administered skills coaching based on behavior therapy
Family members of ED patients
People with ED
Quantitative and qualitative
Quant results not sig. Qualitative: ↑ understanding of how reactions & interactions w/ patients impact outcomes.
Maudsley eating disorder collaborative care workshops (continued)
Macdonald, 2011 (UK)
Aimed at improving communication and reducing social impact of ED for families by addressing negative QOL, burden of illness, distress and expressed emotion. Evidence-based approach, psycho-education principles and motivational interviewing
Family and carers of people with ED
People with anorexia
Skills transfer &supplementary coaching were highly valued; positive change for coaching group & acceptability of intervention
Overcoming Anorexia Online (OAO)
Grover, 2011  (UK)
Aims to provide information, promote self-monitoring and teach skills to identify, understand, and manage Anorexia. Interactive, web-based approach; uses CBT (Williams, 2002, 2009) and systemic framework (Dummett, 2006)
Carers (relatives, partners, friends) of someone with broadly defined anorexia
People with AN, all ages and stages of illness
Main H: ↓ carer distress after OAO supported (vs. controls). Module on communication was most useful.
The care and understanding of people with eating disorders (ENB N46)
Abuel-Ealeh, 2001  (UK)
Aim of program to raise professionals’ knowledge and awareness of EDs; increase confidence and skills for working with ED clients. A university-level course
Mainly nursing students (1 OT; service users)
People with ED (future clients of trainees)
Quantitative descriptive (some open questions)
81.5 % program completers later worked in ED fields; 77.7 % interested in further training
Collaborative care skills training workshops
Pepin & King, 2013  (Australia)
Replication of the Maudsley eating disorder collaborative care workshops in Australia
People with ED living with family members
Quantitative pre-post design + follow-up
↑ adaptive coping strategies over time; ↓ over- Involvement (not EE).
Goodier, 2014  (Australia)
Adaptation of the new Maudsley method for parent skills training with children and adolescents
Parents of children or adolescents in treatment for ED
Children or adolescents with ED
Training helped re: managing illness & family dynamics; broke isolation; peer support
Mental health first aid training course for eating disorders
Hart, 2012  (Australia)
Aims to improve mental health literacy in the social networks of individuals with ED; translates the MHFA protocol, which is an action plan that provides information on various mental illnesses to the public, into a program specifically for EDs
Personal contacts (family, friends, classmates etc.) who may need help for ED
Quantitative; pre-post repeated measures design
↑ ED knowledge & first aid strate-gies; ↓ stigma (social distance); ↑ confidence to identify & help someone with ED.
Chally, 1998  (USA)
A prevention program for school personnel aimed at providing training to recognize students at risk for ED, or to identify signs and symptoms in students with whom they interact daily
High school educators and staff
High school students potentially at risk for ED
Quantitative, pre-post test, control group design
↑ knowledge & ability to identify students at risk; ↑ belief in getting help; ↓ belief that thin = success.
The eating disorder curriculum for primary care providers
Gurni & Halmi, 2001  (USA)
Aims at providing a first step in training social workers to serve as eating disorder therapists in primary care clinics
9 female social workers
minority group members, low-income, at risk for ED
Quantitative (pilot study)
↑ ED knowledge re assessment & treatment; better diagnostic skills post training.
Group Parent Training program (GPT)
Zucker, 2005  (USA)
Assists caregivers in managing the child’s ED, and facilitates a healthy home environment for sustained change. Draws on narrative family therapy and psycho-educational approaches, emotion-focused therapy, mindfulness strategies, dialectical behavior therapy
Parents/carers of patients in the Duke ED Program
Patients in the Duke ED Program
Qualitative (focus groups)
Parent desire for psycho-education materials w/ skills-based approach; ideas re ↑ peer support.
Zucker, 2006  (USA)
Overall aim to maximize the effectiveness of parent involvement while minimizing burden in managing EDs; the main approach used dialectical behavior therapy (DBT) adapted to a group parent format. Course content also based on social cognitive, and learning, theories
Adolescent outpatients from the university affiliated medical center
↑ management of ED, but also better parents; ED skills transfer to other areas; ↑ stress management
Eating disorders and mental health—the EAT framework
DeBate, 2009  (USA)
Aims to increase the capacity of oral health professionals to deliver ED-specific secondary prevention to patients suspected of disordered eating; uses a framework based on transtheoretical model and brief motivational interviewing
Oral health providers
Dental patients suspected of having an ED
Quantitative pre-post design
↑ self-efficacy; ↑ knowledge re oral manifestations of ED, treatments, attitudes re: 2nd-ary prevention
DeBate, 2012  (USA)
To increase knowledge, skill & self-efficacy among dental and dental hygiene students for dealing with oral manifestations of disordered eating; approach is a theory-based framework based on brief motivational interviewing (B-MI)
Dental and dental hygiene students
Dental patients with signs of disordered eating
Quantitative, group randomized control design
↑ improvement vs controls re ED knowledge, oral findings, skills-based knowledge, self-efficacy
The parent partner program™
Haltom, 2012  (USA)
To provide carers with knowledge and skills to support people with ED, but also bring together a community of professionals, carers and advocates around integrated treatment; uses philosophy of mutual support and learning based on research by Bronfenbrenner (Cochran & Henderson, 1986)
Family, friends caring for ED patients
Anyone with ED
Quantitative pre-post test design
↑ knowledge re ED, treatment; how to provide support, ↑ support re carers & empathy re people w/ ED.
Body and self esteem
Rosenvinge, 2003  (Norway)
Increase clinical competence of health providers in ED; encourage interdisciplinary work at local level, and therapists to as ED resources in health care services; approaches: family therapy; CBT); psychodynamic therapy
Local multi-disciplinary health care professionals
Prospective clients of trainees
Quantitative pre-post design + 1 year follow-up
Needed more time to learn clinical skills, management, therapy; ↑ confidence to treat @ follow-up.
Pettersen, 2012  (Norway)
Addresses professionals’ needs for clinical competence and better understanding of the benefits of inter-professional collaboration in treating ED; approach is “exchange based”
Doctors, nurses, psychologists & other health care workers
Desire for ↑ ED services & training after program & to work inter-professionally
The evaluation studies employed a heterogeneous mix of study designs: there were 14 quantitative studies (8 pre-post interventions; 3 RCTs; 3 quantitative descriptive studies); another four were qualitative evaluations, and two used mixed methods. The lack of correspondence between study designs, and characteristics of the training programs (e.g. aims, approaches, populations of interest, outcomes) does not allow for numerical pooling of the outcome data . Thus, a narrative synthesis was conducted.
Training for healthcare and education professionals
Overall, the nine evaluations of ED training for healthcare and education professionals focused on knowledge translation and skill building, prevention, and professional development. Training programs were geared toward specific groups: health care professionals including dentists [10, 11], nurses , social workers , multidisciplinary health professionals [14, 15], and educators [16–18] . Five evaluations found that training significantly improved trainees’ knowledge, skills, and confidence to assess, treat, or teach on eating disorders [10, 11, 15, 17, 18,]. McVey et al.  reported better linkages among ED practitioners, while Rosenvinge et al.  documented strong interest in working inter-professionally, or in starting new services, as a result of training.
Training for families and significant others
Findings from the ten evaluations of ED training for families and other carers also revealed that training improves knowledge and related skills. Yet, most important or this group are findings related to reduced distress and burden, better coping and communication [19–22] and improved family functioning [19, 23]. Trainees needed to be affirmed as good parents, and found that the skills acquired in ED training were transferrable to other areas of parenting [5, 24]. The need for connectedness and support, particularly among parent trainees, emerges as a key theme: being able to break isolation and “externalize the illness” ; the need for ongoing exchange with others [19, 25], and extended support through “alumni groups” or “buddy” systems .
Training for the public
Hart et al.  evaluated a training program that adapted the Mental Health First Aid (MHFA) protocol for serious mental illnesses to ED. They demonstrated that ED knowledge and helping strategies may be effectively disseminated to the general public. The MHFA training was associated with more accurate recognition of eating disorders, greater knowledge of effective treatments and helping strategies, and confidence in providing help.
Discussion and conclusions
This review underlines the international scope of interest in ED training, and a more frequent focus on training for people with an ED diagnosis than on prevention. While all the evaluations assessed outcomes for trainees, very few included questions on training effectiveness from the patient perspective; and none controlled for possible confounding influences on training outcomes. Future research is needed to determine the intensity of training required to sustain improvements in ED knowledge and skills. As well, follow-up studies should establish a stronger link between improved knowledge and better care for sufferers. It would also be important to develop training fidelity measures.
The results suggest that the orientation of ED training varies with the interests and needs of different trainee groups. Whereas healthcare professionals and educators are concerned with the overall development of the ED field, and dissemination of best practices, training for the public at-large promotes familiarity with ED and actual contact between ordinary citizens and ED patients, addressing the critical issues of social distance and stigma in mental health populations [28, 29]. Moreover, family involvement with ED is particularly intense and personal, identifying them as not only trainees, but a potentially vulnerable target group. Results suggest that the supportive, face-to-face element of training for families and natural supporters, both between trainers and trainees and among trainees themselves, was highly beneficial. This implies that ED training using passive learning approaches may be less effective for families, for whom the lived experience of training was an added value.
The heterogeneity of these studies, divergent objectives of the training programs, and the wide array of methodologies employed precluded a more in-depth comparison of individual studies, or subgroups. Nonetheless, the review does provide a comprehensive overview of research on ED training initiatives that should be of interest to healthcare practitioners, educators, and families involved with the management or prevention of ED, as well as the interested public.
1The number of studies reported here totals 22, instead of 20. This occurred because two studies, McVey, 2005, and 2007 cut across two professional groups (healthcare professions and educators), and both age groups (children, and all ages), so are counted twice.
Funding for this research was provided by the Canadian Institutes of Health Research Grant # 261757.
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