International training programs on eating disorders for professionals, caregivers, and the general public: A scoping review

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.


Background
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.

Method
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. [1] The present review used the 6-staged framework for scoping reviews developed by Arksey and O'Malley [2], 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.

Search procedure
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

Selection criteria
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.
The initial electronic search identified 675 articles, with 473 remaining after 202 duplicates were removed. Titles and abstracts of the 473 articles were independently screened for relevance by two researchers (MP and AP) based on the inclusion and exclusion criteria, and 50 articles selected. The same team members then read the selected articles in their entirety. Thirty-four articles (34/50) were excluded for two reasons: 1) the program described was not a training program; or 2) no evaluation of the training was published. This resulted in a total of 14 articles for the review. Disagreements related to the inclusion of papers were discussed and resolved by involving a third team member (JS). The manual search of reference lists for the 14 selected articles resulted in an additional 6 articles, for a total of 20. No further articles emerged from the secondary searches of ED journals, or the organization websites. It should be noted that additional publications exist describing programs for 5 of the 20 selected articles. While not part of the review, these articles may be consulted for supplemental information [3][4][5][6][7]. Fig. 1 presents a flow diagram for the study selection process.

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].

Study characteristics
The 20 evaluation studies reviewed concern a total of 14 ED training programs. The studies represent five countries: Canada (3), UK (5), USA (7), Australia (3), and Norway (2). Table 1 presents the 20 studies in terms of training program identification; training objective/approach; identification of trainee and target populations; evaluation method and findings. The studies included four trainee groups: healthcare professionals (clinicians, students, administrators, and multidisciplinary teams, n = 8); educators (teachers, administrators, school staff, n = 3); natural supporters (parents or other family members, carers, friends, n = 10); and the general public (n = 1). Target populations were children and/or adolescents (n = 8) or people of all ages (n = 14) 1 . For 17 studies the target population had a diagnosed or suspected ED, while the remaining three concerned populations at-risk.
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 [9]. 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 [12], social workers [13], multidisciplinary health professionals [14,15], and educators [16][17][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. [18] reported better linkages among ED practitioners, while Rosenvinge et al. [15] 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][20][21][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" [19]; the need for ongoing exchange with others [19,25], and extended support through "alumni groups" or "buddy" systems [26].

Training for the public
Hart et al. [27] 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.