From one peer to another: Exploring how to incorporate body image conversations into peer support programs for people with disability
K. Alysse Bailey, PhD Candidate, Faculty of Applied Health Sciences, Brock-Niagara Centre for Health and Well-Being, Brock University
Dr. Kimberley L. Gammage, Department of Kinesiology, Brock-Niagara Centre for Health and Well-Being, Brock University
Correspondence concerning this article should be addressed to
K. Alysse Bailey
Faculty of Applied Health Sciences
1812 Sir Isaac Brock Way, St. Catharines,
ON, L2S 3A1, Canada
Peer support programs might be an effective medium for improving body image in people with physical disability. The purpose of the present study was to explore peer mentors’ and mentees’ perspectives on delivering body image information within peer support programs for people with disability. Five participants, four with spinal cord injury and one with cerebral palsy, were interviewed. The four most salient topics discussed were: the timing of body image conversations, the need for conversations to be peer facilitated and client initiated, the challenges of discussing body image, and the benefits of body image discussions. Implications of the study demonstrate the need to train peer mentors and directors of peer mentorship programs on the importance of body image as well as educate them about the construct. Future studies should continue to explore how to disseminate body image information to people with varying disabilities in order to improve body image.
Keywords: Body image; disability; embodiment; well-being, peer support
Body image is a multidimensional concept which reflects how we see, think, feel, and act towards our body’s appearance and function (Cash & Pruzinsky, 2002). These perceptions, thoughts, feelings, and behaviours can be positive or negative in nature and affect many aspects of psychosocial well-being and quality-of-life (Cash & Smolak, 2011). Early body image research was focused on eating pathology and weight and shape concerns among White female university students. It was found that women were particularly dissatisfied with their bodies based on their weight (Cash & Henry, 1995; Rodin, Silberstein, & Striegel-Moore, 1984). Then research exploring body image in men found they were generally dissatisfied with their bodies with regards to muscularity rather than weight (McCreary, 2011).
Research in body image has expanded to include other samples such as middle aged and older adults and people with physical disabilities. A systematic review of both quantitative and qualitative research on body image in older adults by Roy and Payette (2012) demonstrated that body image experiences in Western seniors are both similar and different to body image experiences in younger populations. For example, body dissatisfaction remained stable across the lifespan; however, older adults placed less importance on physical appearance of the body and more on competence. Overall, research about physical disability and body image suggests that a physical impairment can have a negative impact on body image (Burns, Hough, Boyd, & Hill, 2010; Moin, Duvdevany, & Mazor, 2009; Potgieter & Khan, 2005). People with physical disabilities face greater body esteem challenges than the general population, including greater negative feedback from the social environment due to their physical difference (Lawrence 1991; Stone, 1995; Wendell, 1996). However, some people with disability have also been found to have positive body image experiences, particularly in cases when social support is available (Bailey, Gammage, van Ingen, & Ditor, 2015; Taleporos & McCabe, 2002).
Peer support is based on the philosophy that the person who could be most effective at providing support is the one who shares similar experiences (Patterson, Bushnik, Burdsall, & Wright, 2004). Peer mentors are individuals who have successfully adjusted to a particular experience and can provide effective support and empathy to help another person through a comparable experience (Veith, Sherman, Pellino, & Yasui, 2006). Peer mentors share similarities in terms of health conditions and often share characteristics such as age, gender, or culture (Haas, Price, & Freeman, 2013; Webel, Okonsky, Trompeta, & Holzemer, 2010). Peer mentors receive training on how to provide informational, emotional, and appraisal support and use their experiences effectively to help others, which differentiates them from lay persons (i.e., family or friends) who may also provide social support. Peer support has been found to be very effective on a variety of health-related behaviours (e.g., physical activity, medication adherence, cancer screening, smoking cessation, condom use) across a variety of populations (Martin Ginis, Nigg, & Smith, 2013; Webel et al., 2010).
Peer Support and Body Image
In addition to improving health behaviours, a study examined the effectiveness of peer support groups to help prevent disordered eating (McVey, Lieberman, Voorberg, Wardrope, & Blackmore, 2003). They suggested that peer support groups can offer the opportunity for people to work together to explore healthy approaches to eating and body acceptance. In this study, Girl Talk peer support groups were offered to female students attending middle school. The groups were facilitated by local nurses trained on the prevention program, Every BODY Is A Somebody (Seaver, McVey, Fullerton, & Stratton, 1997). The program was developed around two principal components: (a) media literacy about the dangers associated with the idealization of thinness, and (b) the promotion of life skills, including self-esteem and body image enhancement strategies, stress management techniques, and peer relational skills. Overall, the peer support intervention was found to have a positive effect on the girls’ body esteem and eating attitudes and behaviors.
Peer Support and Disability
A handful of studies have explored the effectiveness of the peer support paradigm in people with disability. For example, in people with spinal cord injury, a qualitative study found that peer mentors are useful sources of information for bladder and bowel functioning, sexual functioning, as well as overall emotional and psychological support (Haas et al., 2013). Furthermore, a quantitative study testing the implementation of a peer support intervention for people with spinal cord injury found 67% had an increase in generally perceived self-efficacy, and a significant decrease in urinary tract infections, pain, depression, pressure ulcers, hospitalizations, and emergency visits (Ljungberg, Kroll, Libin, & Gordon, 2011). Lastly, in people with spinal cord injury, developmental disabilities, older adults, and children who are deaf, peer mentorship has been shown to improve physical activity levels (e.g., Lieberman, Dunn, Van der Mars, & McCubbin, 2000).
Peer Support, Body Image and Disability
No studies to our knowledge have explored the use of peer support programs as a medium for delivering body image information to people with physical disabilities. The intended outcome of this study was to understand how body image information should be utilized within peer support programs to inform future intervention efforts that may use this approach to improve body image in people with disability. This study was exploratory as it was the first to investigate the perspectives of individuals with disability from peer support programs about implementing body image discussions into peer support programs. Most of the research that has explored ways to conceptualize, treat, and/or prevent body image issues has been among college students or adolescents, largely neglecting other populations such as people with physical disability (Cash & Smolak, 2011). In fact, body image experiences of people with physical disability have been underrepresented in the body image literature.
It is important to distinguish between two types of physical disabilities, congenital and acquired. A congenital disability is one that is present at birth or shortly after birth (e.g., cerebral palsy and spina bifida) while an acquired disability refers to postnatal changes that result in impairment of the body (e.g., spinal cord injury; Behel & Rybarczyk, 2012). While physical disabilities can be distinguished based on when they occur, the literature on body image and physical disability does not suggest substantial differences between those with congenital versus acquired conditions (e.g., Rumsey & Harcourt, 2011). A quantitative study by Atherton and Robertson (2006) found that men and women with lower limb amputation with prosthesis who were higher in public self-consciousness experienced more distress and concerns with their physical appearance than those low in public self-consciousness. Therefore it was high public self-consciousness that was related to body image distress rather than the disability itself. However, body image in lower limb amputees (Holzer et al., 2014), people with multiple sclerosis (Pfaffenberger et al., 2011) and body image and sexual self-esteem in people with polio and spinal cord injury (Moin et al., 2009) was poorer than in those without disability. In contrast, in two studies, one about men with spinal cord injury (Bassett & Martin Ginis, 2009) and the other about women with spinal cord injury (Bassett, Martin Ginis, & Buchloz, 2009), it was found that body image was not much different than the general population. Lastly, in qualitative studies (Bailey et al., 2015; Taleporos & McCabe, 2002) there is evidence suggesting that individuals with physical disabilities (e.g., spinal cord injury, cerebral palsy, brittle bone disease) gradually adjust to their bodies and increasingly accept their disabilities over time particularly when social support is present and acceptance from others is unconditional. Therefore, body image in people with physical disability may depend on factors such as severity of disability, time with disability, age of onset, as well as individual personality and social factors.
One method to facilitate the process of body acceptance and overall positive body adjustment to a physical disability could be through peer support. Emotional, social, and informational support from similar peers could help clients learn to accept and appreciate their bodies. For example, Carpenter (1994) found that patients emulated their expert peers; therefore, clients may learn from and emulate their peers when it comes to having a more accepting and appreciative view of the body. Disseminating body image information through existing peer support programs may be a relatively cost effective and simple strategy to improve body image in people with disability. Knowledge mobilization, which is the proactive process of delivering knowledge from research to the people who need it the most (Lavis et al., 2003), is needed within the body image domain. A meta-analytic review demonstrated that psychoeducation was associated with improved body image (Alleva, Sheeran, Webb, Martijn, & Miles, 2015). Peer support organizations may be an effective medium of knowledge mobilization and psychoeducation to deliver body image information to people with physical disabilities. Lavis and his colleagues (2003) developed a theoretical framework that highlights the interplay between research production and knowledge mobilization: (a) tailor messages and practice to suit the audience, (b) understand the target audience, (c) use credible messengers, (d) use effective methods for conveying messages, and (e) measure the effectiveness of knowledge mobilization. The purpose of the present qualitative study was to explore (a) to (d) by interviewing peer mentors and mentees to gain perspective on delivering body image information within peer support programs for people with disabilities.
Peer Support Program Contexts
Participants were primarily involved in two different peer support organizations from the Southern Ontario area. One organization was open for people with spinal cord injury. This organization, which has run its peer support program for over 16 years, had approximately 80 peer mentor volunteers. At any point after injury, a client may request a peer support mentor to help them deal with life after a spinal cord injury. Mentees and mentors are carefully matched by a peer support director on age, ethnicity, sex, language spoken, family status, special interests, level of injury, employment status, cause of injury, and availability. Popular topics of discussion between mentors and mentees include intimacy, sexual functioning, childbirth, and bladder/bowel routine after injury. The second organization was a newer peer support program running for about three years and was open to anyone who identified with having a disability. Mentors and mentees were matched based on life experiences and goals (e.g., housing applications, human rights cases) at this organization.
Five participants (three men and two women) residing in Southern Ontario volunteered to participate in this study. Four participants had spinal cord injury and one participant had cerebral palsy. Participants were recruited if they met the following criteria: 18 years of age or older, had a physical disability, and had experience as a mentor or mentee within a peer support program. All names in the study are presented as pseudonyms for anonymity purposes. Three participants (Ralph, Bob, and Breanna) were peer support mentors recruited from a peer support program and Dough and Lauren were recruited through a university exercise facility which had a specialized program for people with spinal cord injury. Dough had experience as both a mentee and mentor and Lauren experience as a mentee. To maintain credibility of data sources, we recruited only those who had experience in peer support programs, thereby limiting our sample size. It is important to note that challenges were experienced working with gatekeepers of the peer support programs who limited opportunities for recruitment. According to Patton (2002), qualitative sample sizes should be small so that data analysis can be thorough and in-depth rather than superficial and overwhelming. Refer to Table 1 for participant characteristics.
The Research Team
The research team included three individuals, all of whom were Caucasian varying in research experience and expertise and did not identify with having a physical disability. The lead author was a female doctoral student. She developed the research idea, the interview guide, and conducted and analyzed all the interviews. The second author was a female faculty member with extensive research experience in the area of body image and self-presentational concerns across the lifespan. Lastly, there was a fourth year undergraduate student research assistant. She was responsible for transcribing and analyzing all the interviews.
Demographic form. A fact sheet was used to gather information about participants’ age, gender, race, level of injury, age at time of injury, severity of injury, and the American Spinal Injury Association Impairment Scale (AIS) grade (if known and applicable).
Interview guide. The interview guide was developed to explore the thoughts and perspectives of implementing body image into an already established peer support program. Refer to Table 2 for a list of questions in the interview guide.
Upon university research ethics clearance, participants were recruited via posters placed around the university campus or via email by peer support directors who acted as gatekeepers for the project. Posters advertised for participants with experience in a peer support program to participate in a one-on-one interview about their perspective of implementing body image information into peer support programs for people with physical disability. Participants emailed the first author if they were interested in participating in the study. Potential participants were emailed a letter of invitation outlining more details about the study. Then, a one-on-one interview was scheduled with the first author and took place either at the participant’s own home or in a private lab at the university. All participants signed an informed consent form and completed a demographic form before the interview. All interviews were audio-recorded and ranged between 30 minutes to one hour in length.
Audio-recordings were transcribed verbatim by the student research assistant and pseudonyms were assigned to each participant for anonymity purposes. Thematic analysis was employed for identifying, analyzing and reporting patterns or themes in the data (Braun & Clarke, 2006). This analysis remained flexible within the multiple epistemological orientations of the authors but was primarily grounded within the first author’s constructivist framework (Lincoln, Lynham, & Guba, 2011). As a constructivist, her extensive research within positive body image and special populations informed and complemented the analysis.
The first author and her student research assistant immersed themselves in the transcripts reading them carefully multiple times in an active way searching for meaning and patterns. Transcripts were coded inductively, where initial codes were identified as reoccurring patterns. The next step was searching for themes which involved sorting related codes into potential themes. This process remained flexible whereby themes were modified and refined until the most coherent reconstruction of the data was completed (Braun & Clarke, 2006).
We followed Lincoln and Guba’s (1986) recommendations for ensuring the trustworthiness, authenticity, and credibility of the data. For example, credibility of data was maintained by having those with physical disability who have direct experience with peer support programs as participants for this study. Member checking was used to ensure the participant’s thoughts, feelings, and beliefs were interpreted correctly. Authenticity is maintained by having participant’s own words displayed as direct quotations within the results. Two independent coders analyzed the data to apply their separate ideas and concepts to the analysis which helped ensure trustworthiness of the data. The first author and her research assistant coded 100% of the transcripts. Triangulation of data (e.g., interviews and field notes) and researcher triangulation of concepts were used to gather multiple perspectives to strengthen final results.
Overall, participants found a lot of value in delivering body image information into peer support programs; however they had some reservations and recommendations. The four most salient topics discussed were: timing of body image conversations, conversations peer facilitated and client initiated, challenges of discussing body image, and benefits of body image discussions. All the main themes are delineated below.
Timing of Body Image Conversations
All five participants described the timing of body image conversations to be crucial. Bob described that clients with spinal cord injury who are recently injured and still in the hospital would not be ready to discuss body image. Rather, he thought body image conversations would be more appropriate after clients are home from the hospital. Lauren explained that during the hospital after her spinal cord injury she was on so many painkillers that she would not have been able to coherently discuss body image. She said,
I’m thinking back to when I was first recovering and I was barely able to lift my arm up to feed myself and there wasn’t anything that would’ve helped. Thank God, my GP [general practitioner] gave me enough painkillers to help the pain because I was on a lot of painkillers. I was taking more than most of his cancerous patients and eventually over the last couple of years I’ve been able to ween myself off of all of the painkillers.
When Lauren was asked when would be a good time to introduce the topic body image, she said, “Well, once a person is… has gotten a little more comfortable with their situation and off painkillers because when I took so many painkillers my mind was groggy.” Lauren continued to describe that once someone is home from the hospital they would be ready to discuss body image. Dough described how important he felt peer support was. He said,
I’m a strong believer that I think people coming out of hospital and coming out of rehab need a lot of peer support. I think it’s vitally important, I think you learn more from talking with and being around people and just speaking with other people who’ve got the same injury, that have gone through the same problem or in my case passing what I’ve learned from going through this to other people, so they can learn through it.
Dough believed peer support to be important for learning about any topic about spinal cord injury, including changes to body image. It was suggested that after one year post-injury body image could be discussed for people with spinal cord injury because the adjustment in the first year could be too overwhelming. Since Breanna had cerebral palsy and was a peer mentor for someone with any type of disability, she felt body image could be introduced as soon as the client was ready to talk about their body.
Conversations Peer Facilitated and Client Initiated
All participants felt conversations about body image should be facilitated by a peer with similar experiences because peers are a credible source. For example, Dough said,
... to hear from someone who has gone through it is much more important to me and to most people more meaningful than hearing it from some therapist … cause you know if you’re very able bodied and able to do things, umm… it’s tough to have credibility tell somebody who’s, you know, got motor skill problem ‘Oh yes, I understand.’ No… no you don’t, you might understand the science of it but you’ll never understand cause you’ve never gone through it.
Breanna described that peer support volunteers would be perfect for talking about body image with their clients. In fact, during the interview she realized that she would be equipped to discuss the topic with her clients.
Ralph and Bob felt strongly about the conversations being initiated by the client. For example, Ralph said,
I think it’s difficult right because it’s one of those things that you just wouldn’t bring up to somebody about their appearance right, because everybody is different... I think it would be one of those things where somebody’s expressed the issue about, you know, if I have lost my identity now and how can I look like you... I think that would be an appropriate avenue to bring that up or opportunity to bring that up. I think you really have to wait for that window of opportunity to be able to present that to somebody.
Overall, participants felt peers were a credible source of information when it comes to body image; however that it might be safer to wait for the client to bring up the topic on their own especially if the topic targets appearance.
Challenges of Discussing Body Image
All participants discussed some challenges with discussing body image with their clients. Two main challenges were considered: (a) what topics should be discussed and (b) when the topics should be discussed. Participants were concerned with what to discuss especially since they thought appearance was the main component of body image. Discussing someone’s appearance was proposed as a touchy topic that may only worsen body image. Breanna mentioned that body image was a topic that is emotional. She said, “Because you as the mentor you feel like you’re causing some kind of turmoil by discussing body image.” She also said, “It’s very emotional. I did a lot of crying when I was trying to figure out why I didn’t like myself.”
The other challenge was when to discuss body image. Since it was suggested in the previous theme that an appropriate avenue or window of opportunity had to be presented by the client to broach the subject, what would this mean if clients never brought the topic up on their own? Ralph explained that it would be difficult to know when that “window of opportunity” is presented, creating an additional challenge to discussing body image with clients.
Benefits of Body Image Discussions
All participants mentioned some benefits of implementing body image into peer support programs. Breanna thought body image played a huge role in a peer support program. She said,
It’s huge, because let’s say you have a disabled person comes in and they’re feeling down on themselves and the way they look, whatever, and they see the person helping them have a disability, you know what it’s going to be like, “well if they can do that then why can’t I do that?’
Based on Breanna's own personal body image journey with her disability and recently gaining weight, she felt body image was crucial for clients. In fact, she expressed a lot of emotion on the topic and described body image impacting her life almost every day. Her passion on the topic gave her courage to start discussing body image with future clients.
Another benefit expressed by participants was if clients could come to a place of acceptance with their body. Ralph felt that peer mentors keeping a positive spin on circumstances would help clients accept their body. He said,
... you know share the positive side of things. Umm, but again you want to be realistic too is that, you know, if there’s something that you can’t do for yourself, you do have to ask for help, but I think it’s extremely important to really stress the positive things just figuring out what you can do for yourself and then just adapting to your environment is important, too.
Overall, although participants anticipated challenges with delivering body image information, they also saw a lot of value and believed it could help clients have a higher quality of life.
This study was designed to explore peer mentors’ and mentees’ perspectives of implementing body image discussions into peer support programs for people with disabilities. Overall, participants felt body image was an important topic that should be included into discussion with clients; however they discussed some potential challenges and provided recommendations which helped provide direction for knowledge mobilization in future projects.
The first important discussion was the timing of information. Since body image can be a sensitive topic, it was suggested that for people with spinal cord injury who are recently injured, that they would not be ready to discuss body image right away. Rather, once clients were home and more adjusted to their injury they would be ready to discuss body image experiences with their peer mentors. In a qualitative study by Letts et al. (2011) they explored how to deliver physical activity information to people with spinal cord injury and found timing was an important factor. Generally, during time at the hospital acutely after injury was too early as patients are overwhelmed by information about their injury. Rather, any time after inpatient rehabilitation was preferred by participants. For people with a different type of disability such as a congenital disability (e.g., cerebral palsy), it was suggested body image conversations could start as soon as the client seemed ready. During childhood, the family environment is a significant influence on body image development (Rumsey & Harcourt, 2011). It may be advantageous for peer mentors to discuss body image with parents to help promote positive body image within the family and instill a positive body image at an early age in children. Therefore, depending on the type of disability (acquired or congenital) timing of body image information delivery may vary. Peer mentors should be cognizant of the timing of when they deliver body image information to their clients and be sensitive to the type of their disability. On the contrary, body image may worsen if peers wait too long to provide information about body image. For instance, in people with spinal cord injury, the time acutely after injury has been shown to be very poor for body image (Bailey, Gammage, van Ingen, & Ditor, 2016a; Bailey, Gammage, van Ingen, & Ditor, 2016b). Therefore, as soon as the client is more adjusted to the injury itself, body image may need to be targeted immediately. Furthermore, research has shown that body image is most negatively impacted if disability or visible difference is acquired during the time period of adolescence (Behel & Rybarczyk, 2012; Rumsey & Harcourt, 2004). This is because appearance and social acceptance are salient at this stage; therefore, peer mentorship may be particularly important for adolescents with congenital or acquired disability.
The second finding was that peers were a credible source of information about body image. This is consistent with previous literature (Letts et al., 2011) which found peers were a credible source of health and physical activity information because they have similar characteristics and circumstances. Therefore, there is a need to train peer mentors on body image (characteristics of positive body image and not internalizing the ideal) to prepare them for conversations with clients to deliver effective information to improve body image. Furthermore, in the present study, participants believed conversations about body image should be client initiated. This finding could be due to participants not having a complete understanding of the construct of body image. For instance, Ralph and Dough felt body image was restricted to one’s outer appearance; therefore by broaching the topic a peer mentor may offend their client. Also, there is the added challenge as there could be instances when clients need information about body image but are too shy to broach the topic themselves. Therefore, perhaps peer mentors who are trained to deliver body image information could emphasize positive body image (e.g., appreciation, acceptance, respect for the body; Tylka & Wood-Barcalow, 2015) thereby not offending their client since the emphasis is not on appearance. It is important peer mentors are properly trained on positive body image to not perpetuate negative notions about the body, such as reinforcing the ideal and placing overemphasis on appearance.
We present some important recommendations to overcome the challenges offered by participants in this study. It is important to consider how to get buy-in with gatekeepers of organizations where body image information might be important. It may be body image experts’ responsibility to educate potential gatekeepers of peer support programs on the importance and relevance of body image. Gatekeepers may not have the knowledge about why body image information would be needed for clients. Experts should come prepared with a short presentation of background on body image, the construct definition, as well as relevant findings from the literature, particularly related to those with physical disability. This added step in knowledge mobilization may facilitate dissemination of body image information into peer support programs.
Lastly, there were some lessons learned about working with gatekeepers on a body image project. A gatekeeper is a person who has access and/or particular status with a group of people and who can facilitate or impede access for others to enter (Liamputtong, 2013). Gatekeepers, such as managers or directors, can largely determine researchers’ access to study participants as they can withhold or grant access to peer support volunteers. Rarely are challenges with recruitment acknowledged even though lessons learned can greatly assist future researchers down the road (Bailey, Baker, Spassiani, & Meisner, 2012). In the present study, the gatekeeper of the spinal cord injury peer support program believed the topic body image was important but he also believed the peer support program itself did not need to be changed to include body image. Further, his understanding of body image was limited to appearance (rather than function and health). Potentially, if he had had a broader understanding of the construct more in line with the current literature definition and more knowledge about how body image impacts people with disability (e.g., Taleporos & McCabe, 2002) then maybe he would see a greater need for the topic to be covered in the peer support program. Since recruitment was limited by him, his opinion about the topic was very important. Moving forward, it is important that body image researchers educate gatekeepers about the construct prior to recruitment to ensure everyone is on the same page and recruitment can run smoothly. It is important that peer support directors do not think the suggestion of adding body image information is meant to imply their existing programs are not ‘good enough’. Instead, gatekeepers should be assured that the addition of body image information would complement the existing format and content of the peer support program since the topic is related to issues of weight and sexuality, topics already included. Lastly, it is important to recognize there may be other reasons gatekeepers may not facilitate this process, such as protecting the organization, clients, and volunteers for their time and commitment to such projects. Regardless, it is critical to gain buy-in from the gatekeepers to ensure body image content is integrated into peer support programs effectively.
The present study addressed the following knowledge mobilization components developed by Lavis and his colleagues (2003): (a) tailor messages and practice to suit the audience, (b) understand the target audience, (c) use credible messengers, and (d) use effective methods for conveying messages. From the findings of this study it was learned that body image information delivered to clients of a peer support program for people with physical disability must be tailored to fit the needs of the client. One suggestion was making sure information always had a positive focus, emphasizing function and adaptations of the body rather than emphasizing or trying to change perceived shortcomings. Another important finding was with regards to understanding the target audience. Participants emphasized how it was important to be sensitive to the client’s type of disability. For example, if the client has a recent spinal cord injury, body image information may need to be delivered later when the client is more adjusted and out of the hospital. With regards to using credible messengers, all participants believed peers were a credible source of body image information because they shared similar characteristics or circumstances. Lastly, in regards to using effective methods for conveying messages, participants felt informal peer mentor-mentee conversations were an appropriate means for delivering body image information; however, they felt it might be safer for clients to initiate the conversation. Body image knowledge production is seldom transferred to the areas of most needed attention. The use of peer support programs could be a relatively simple and cost effective strategy to disseminate meaningful research to clients who are adjusting to a physical disability.
The present study clearly demonstrates the practicality of implementing body image information into peer support programs. One implication might be the need for peer mentors to be trained and equipped with a checklist of topics related to body image that may need to be covered. Since sexual functioning was listed as a popular topic, body image may complement this discussion. If peer mentors were prepared with a tangible list of important body image topics (e.g., acceptance, appreciation, function of the body), then it may increase the likelihood of these discussions being covered. Pruzinsky (2004) made a compelling argument for more effective screening of body image within the medical context to assist practitioners in recognizing body image distress. Peer support programs may be an ideal context for administering screening of body image, such as peer mentors administering the Body Image Quality of Life Inventory (Cash & Flemming, 2002) to clients. This strategy may help overcome the issue of when to implement body image conversations as it would help introduce the topic and evaluate the client's current body image as well as normalize body image assessment. Furthermore, enhancing social support through the use of peer support may promote positive body image since social support, unconditional acceptance from others, and surrounding oneself with positive others has been found to foster positive body image (e.g., Bailey et al., 2015; Tylka, 2011; Wood-Barcalow, Tylka, & Augustus-Horvath, 2010).
Limitations and Future Directions
The results of this study provide direction regarding dissemination of body image information to people with disability through the use of peer support programs; however, there are some limitations that should be noted. First, the characteristics of our sample represent a limitation. Our sample was predominately people with spinal cord injury, with only one person with a congenital disability. This limits the breadth of perspectives on delivering body image information to people with varying disabilities. This limitation highlights the need to conduct further research exploring ways to disseminate body image information to people of varying disabilities. As noted earlier, there were some challenges working with gatekeepers of the peer support programs to recruit peer mentors or mentees thereby limiting the sample for the current study. Furthermore, future studies should evaluate if screening of body image within peer support programs and medical contexts is effective at detecting body image distress and initiating conversations. Lastly, future studies could be conducted to see if the delivery of body image material in peer support programs actually improves body image. The literature suggests that body image concerns are particularly problematic during the developing years for both girls and boys (Grogan, 2017). This highlights the need to provide body image information to individuals younger than those in the current study. Future research is needed to explore the effectiveness of peer support volunteers providing body image information to young populations and their families.
Peer support programs may be a viable and cost effective method for disseminating important information about body image to clients with varying disabilities. The current study provides important direction for future researchers to work with peer support programs to train mentors on the type of information to deliver, the timing of information delivery, and some potential challenges and benefits they may encounter. Lastly, the lessons learned from this study was the importance of buy-in to get gatekeepers of peer support organizations compliant to body image intervention efforts as well as for researchers to not assume gatekeepers and mentors have an accurate interpretation of the construct.
Alleva, J. M., Sheeran, P., Webb, T. L., Martijn, C., & Miles, E. (2015). A meta-analytic review of stand-alone interventions to improve body image. PloS One, 10, e0139177. https://doi.org/10.1371/journal.pone.0139177
Atherton, R., & Robertson, N. (2006). Psychological adjustment to lower limb amputation amongst prosthesis users. Disability and Rehabilitation, 28, 1201-1209. http://dx.doi.org/10.1080/09638280600551674
Bailey, K. A., Baker, J., Spassiani, N. A., & Meisner, B. A. (2012). Differences among Gatekeepers of gerontological research: A pilot study investigating factors influencing research compliance. Research on Aging, 34, 499-506. https://doi.org/10.1177/0164027512444290
Bailey, K. A., Gammage, K. L., van Ingen, C., & Ditor, D. S. (2015). “It’s all about acceptance”: A qualitative study exploring a model of positive body image for people with spinal cord injury. Body Image, 15, 24-34. http://dx.doi.org/10.1016/j.bodyim.2015.04.010
Bailey, K. A., Gammage, K. L., van Ingen, C., & Ditor, D. S. (2016a). Managing the stigma: Exploring body image experiences and self-presentation among people with spinal cord injury. Health Psychology Open, 3, 1-10. http://dx.doi.org/10.1177/2055102916650094
Bailey, K. A., Gammage, K. L., van Ingen, C., & Ditor, D. S. (2016b). “My body was my temple”: A narrative revealing body image experiences following treatment of a spinal cord injury. Disability and Rehabilitation, 1-7. http://dx.doi.org/10.1080/09638288.2016.1211753
Bassett, R. L., & Martin Ginis, K. A. (2009). More than looking good: Impact on quality of life moderates the relationship between functional body image and physical activity in men with spinal cord injury. Spinal Cord, 47, 252-256. http://dx.doi.org/10.1038/sc.2008.114
Bassett, R. L., Martin Ginis, K. A., & Buchholz, A. C. (2009). A pilot study examining correlates of body image among women living with spinal cord injury. Spinal Cord, 47, 496-498. http://dx.doi.org/10.1038/sc.2008.174
Behel, J. M., & Rybarczyk, B. D. (2012). Physical disability and body image in adults. In T. F. Cash (Ed.), Encyclopedia of body image and human appearance (pp. 644-648). London, UK: Academic Press. http://dx.doi.org/10.1016/c2010-1-66177-9
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. http://dx.doi.org/10.1191/1478088706qp063oa
Burns, S. M., Hough, S., Boyd, B. L., & Hill, J. (2010). Men’s adjustment to spinal cord injury: The unique contribution of conformity to masculine gender norms. American Journal of Men’s Health, 4, 157-166. http://dx.doi.org/10.1177/1557988309332690
Carpenter, C. (1994). The experience of spinal cord injury: The individual's perspective -implications for rehabilitation practice. Physical Therapy, 74, 614-628.
Cash, T. F., & Fleming, E. C. (2002). The impact of body image experiences: Development of the body image quality of life inventory. International Journal of Eating Disorders, 31, 455-460. https://doi.org/10.1002/eat.10033
Cash, T. F., & Henry, P. E. (1995). Women’s body images: The results of a national survey in the USA. Sex Roles, 33, 19-28. https://doi.org/10.1007/bf01547933
Cash, T. F., & Pruzinsky, T. (2002). Future challenges for body image theory, research, and clinical practice. In T. F. Cash & T. Pruzinsky (Eds.), Body image: A handbook of theory, research, and clinical practice, (2nd ed., pp. 509-516). New York, NY: Guilford Press.
Cash, T. F., & Smolak, L. (2011). Understanding body images: Historical and contemporary perspectives. In T. F. Cash & L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (2nd ed., pp. 3–11). New York, NY: The Guilford Press.
Haas, B. M., Price, L., & Freeman, J. A. (2013). Qualitative evaluation of a community peer support service for people with spinal cord injury. Spinal Cord, 51, 295-299. http://dx.doi.org/10.1038/sc.2012.143
Holzer, L. A., Sevelda, F., Fraberger, G., Bluder, O., Kickinger, W., & Holzer, G. (2014). Body image and self-esteem in lower-limb amputees. PloS One, 9, e92943. http://dx.doi.org/10.1371/journal.pone.0092943
Lavis, J. N., Robertson, D., Woodside, J. M., McLeod, C. B., & Abelson, J. (2003). How can research organizations more effectively transfer research knowledge to decision makers? Milbank Quarterly, 81, 221-248. http://dx.doi.org/10.1111/1468-0009.t01-1-00052
Lawrence, B. (1991). Self-concept formation and physical handicap: Some educational implications for integration. Disability, Handicap and Society, 6, 139-146. https://doi.org/10.1080/02674649166780161
Liamputtong, P. (2013). Qualitative research methods (4th ed.). South Melbourne, Australia: Oxford University Press.
Lieberman, L. J., Dunn, J. M., Van der Mars, H., & McCubbin, J. (2000). Peer tutors' effects on activity levels of deaf students in inclusive elementary physical education. Adapted Physical Activity Quarterly, 17, 20-39. https://doi.org/10.1123/apaq.17.1.20
Letts, L., Martin Ginis, K. A., Faulkner, G., Colquhoun, H., Levac, D., & Gorczynski, P. (2011). Preferred methods and messengers for delivering physical activity information to people with spinal cord injury: A focus group study. Rehabilitation Psychology, 56, 128-137. http://dx.doi.org/10.1037/a0023624
Lincoln, Y. S., Lynham, S. A., & Guba, E. G. (2011). Paradigmatic controversies, contradictions, and emerging confluences, revisited. In N. K. Denzin & Y. S. Lincoln (Eds.), Sage handbook of qualitative research (pp. 97-128). Thousand Oaks, CA: Sage.
Lincoln, Y. S., & Guba, E. G. (1986). But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. In D. D. Williams (Ed.), Naturalistic evaluation (pp. 73-84). San Francisco, CA: Jossey-Bass. http://dx.doi.org/10.1002/ev.1427
Ljungberg, I., Kroll, T., Libin, A., & Gordon, S. (2011). Using peer mentoring for people with spinal cord injury to enhance self‐efficacy beliefs and prevent medical complications. Journal of Clinical Nursing, 20, 351-358. https://doi.org/10.1111/j.1365-2702.2010.03432.x
Martin Ginis, K. A., Nigg, C. R., & Smith, A. L. (2013). Peer-delivered physical activity interventions: An overlooked opportunity for physical activity promotion. Translational Behavioral Medicine, 3, 434-443. http://dx.doi.org/10.1007/s13142-013-0215-2
McCreary, D. R. (2011). Body image and muscularity. In T. F. Cash & L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (2nd ed., pp. 198-205). New York, NY: The Guilford Press. http://dx.doi.org/10.1016/b978-0-12-384925-0.00088-2
McVey, G. L., Lieberman, M., Voorberg, N., Wardrope, D., & Blackmore, E. (2003). School-based peer support groups: A new approach to the prevention of disordered eating. Eating Disorders, 11, 169-185. https://doi.org/10.1080/10640260390218297
Moin, V., Duvdevany, I., & Mazor, D. (2009). Sexual identity, body image and life satisfaction among women with and without physical disability. Sexuality and Disability, 27, 83-95. http://dx.doi.org/10.1007/s11195-009-9112-5
Patterson, R., Bushnik, T., Burdsall, D., & Wright, J. (2004). Considerations of peer support for persons with high tetraplegia. Topics in Spinal Cord Injury Rehabilitation, 10, 30-37. http://dx.doi.org/10.1310/n1uw-85ur-prt6-9mwy
Patton, M. Q. (2002). Qualitative research and evaluation methods. Thousand Oaks, CA: Sage Publications.
Pfaffenberger, N., Gutweniger, S., Kopp, M., Seeber, B., Stürz, K., Berger, T., & Günther, V. (2011). Impaired body image in patients with multiple sclerosis. Acta Neurologica Scandinavica, 124, 165-170. http://dx.doi.org/10.1111/j.1600-0404.2010.01460.x
Potgieter, C., & Khan, G. (2005). Sexual self-esteem and body image of South African spinal cord injured adolescents. Sexuality and Disability, 23, 1-20. http://dx.doi.org/10.1007/s11195-004-2076-6Siddall
Pruzinsky, T. (2004). Enhancing quality of life in medical populations: A vision for body image assessment and rehabilitation as standards of care. Body Image, 1, 71-81. http://dx.doi.org/10.1016/s1740-1445(03)00010-x
Rodin, J., Silberstein, L., & Striegel-Moore, R. (1984). Women and weight: A normative discontent. Nebraska Symposium on Motivation, 32, 267-307.
Roy, M., & Payette, H. (2012). The body image construct among Western seniors: A systematic review of the literature. Archives of Gerontology and Geriatrics, 55, 505-521. http://dx.doi.org/10.1016/j.archger.2012.04.007
Rumsey, N., & Harcourt, D. (2004). Body image and disfigurement: Issues and interventions. Body Image, 1, 83-97. https://doi.org/10.1016/s1740-1445(03)00005-6
Rumsey, N., & Harcourt, D. (2011). Body image and congenital conditions resulting in visible difference. In T. F. Cash & L. Smolak (Eds.) Body image: A handbook of science, practice, and prevention (pp. 253-260). New York, NY: The Guildford Press.
Seaver, A., McVey, G., Fullerton, Y., & Stratton, L. (1997). Every BODY is a Somebody: An active learning program to promote healthy body image, positive self-esteem, healthy eating and an active lifestyle for adolescent females: Teachers’ Guide. Brampton, ON: The Body Image Coalition of Peel.
Taleporos, G., & McCabe, M. P. (2002). Body image and physical disability—personal perspectives. Social Science and Medicine, 54, 971-980. http://dx.doi.org/10.1016/s0277-9536(01)00069-7
Tylka, T. L. (2011). Positive psychology perspectives on body image. In T. F. Cash &L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (2nd ed., pp. 56–64). New York, NY: The Guilford Press. http://dx.doi.org/10.1016/b978-0-12-384925-0.00104-8
Tylka, T. L., & Wood-Barcalow, N. L. (2015). What is and what is not positive body image? Body Image, 14, 118–129. http://dx.doi.org/10.1016/j.bodyim.2015.04.001
Veith, E. M., Sherman, J. E., Pellino, T. A., & Yasui, N. Y. (2006). Qualitative analysis of the peer-mentoring relationship among individuals with spinal cord injury. Rehabilitation Psychology, 51, 289-298. http://dx.doi.org/10.1037/0090-5518.104.22.1689
Webel, A. R., Okonsky, J., Trompeta, J., & Holzemer, W. L. (2010). A systematic review of the effectiveness of peer-based interventions on health-related behaviors in adults. American Journal of Public Health, 100, 247-253. http://dx.doi.org/10.2105/ajph.2008.149419
Wendell, S. (1996). The rejected body: Feminist philosophical reflections on disability. London, England: Psychology Press.
Wood-Barcalow, N. L., Tylka, T. L., & Augustus-Horvath, C. L. (2010). “But I like my body”: Positive body image characteristics and a holistic model for young-adult women. Body Image, 7, 106-116. http://dx.doi.org/10.1016/j.bodyim.2010.01.001
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
This research received no specific grant from any funding agency in the public, commercial, or not-for profit sectors.
Author Biographical Notes
K. Alysse Bailey is a doctoral student at Brock University in the Faculty of Applied Health Sciences whose research interests include understanding and improving body image experiences in diverse samples (e.g., older adults and individuals with various physical disabilities).
Dr. Kimberley L. Gammage is an associate professor at Brock University in the Department of Kinesiology whose research interests include body image and self-presentation and their impact on psychological states and health behaviours across the lifespan.
International Journal of Disability, Community &
Volume 16, No. 1