Eating Disorders The Journal of Treatment & Prevention
ISSN: 1064-0266 (Print) 1532-530X (Online) Journal homepage: http://www.tandfonline.com/loi/uedi20
Words on Walls: Passive Eating Disorder Education Mary E. Duffy & Kristin E. Henkel To cite this article: Mary E. Duffy & Kristin E. Henkel (2015): Words on Walls: Passive Eating Disorder Education, Eating Disorders, DOI: 10.1080/10640266.2015.1034054 To link to this article: http://dx.doi.org/10.1080/10640266.2015.1034054
Published online: 16 Apr 2015.
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Date: 05 November 2015, At: 13:49
Eating Disorders, 00:1–13, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2015.1034054
Words on Walls: Passive Eating Disorder Education MARY E. DUFFY and KRISTIN E. HENKEL
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Department of Psychology, University of Saint Joseph, West Hartford, Connecticut, USA
This study examined the effect of a short-term passive intervention on nursing students’ beliefs about eating disorders (EDs). Before and after a weeklong ED education poster campaign, participants completed questionnaires assessing their attitudes about individuals with EDs. Results showed a reduction in the belief that people with EDs are almost always women, increased attribution to biological and genetic factors, and decreased attribution to society’s thin ideal. Personal connection moderated response to the items: [people with EDs] “are putting their lives at risk” and “would not improve with treatment.” This intervention shows promise for reducing ED-associated stereotype endorsement among medical professionals.
Stigma is the negative evaluation of, and attitude towards, a group on the basis of a stereotype-linked attribute of that group. Individuals with mental illness are subject to stigma, usually in relation to perceived flaws in character (Goffman, 1963). The “undesirable differentness” of stigmatized individuals becomes their defining characteristic, overriding their actual characteristics and identity, typically with negative effects (Goffman, 1963, p. 4). People with eating disorders are one such stigmatized group. Researchers have established a number of damaging, stigmatizing beliefs about individuals with eating disorders. Widespread public attitudes frame eating disorders as irrational, self-inflicted conditions (Rich, 2006). Several studies have replicated the finding that the public believes people with eating disorders are more “to blame for their condition” and more able to “pull themselves together if they wanted to” than people with other mental and physical disorders, including: asthma, depression, schizophrenia, panic
Address correspondence to Mary E. Duffy, Department of Psychology, University of Saint Joseph, 1678 Asylum Avenue, West Hartford, CT 06117, USA. E-mail: [email protected] 1
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attacks, alcoholism, or drug addiction (e.g., Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000; Roehrig & McLean, 2010; Stewart, Keel, & Schiavo, 2006). In addition, people with eating disorders are perceived to be “acting this way for attention” (Rich, 2006; Roehrig & McLean, 2010; Stewart et al. 2006). Stewart et al. (2006) explain the stereotype that eating disorders occur only in adolescent girls may contribute to beliefs that eating disorders are caused by body dissatisfaction and factors such as parenting and lack of social support. While socio-cultural factors can influence risk for disordered eating (e.g. Becker, 2004), they are not the sole causal factor. A lack of knowledge of the biological and genetic bases of anorexia nervosa may be one reason individuals with the disorder are blamed and held responsible for their condition (Crisafulli, Thompson-Brenner, Franko, Eddy, & Herzog, 2010; Crisafulli, Von Holle, Bulik, 2008). In one intervention, education about the genetic and biological causes of eating disorders reduced beliefs that eating disorders are volitional and controllable (Crisafulli et al., 2008). Overall, stigmatizing beliefs about eating disorders serve to frame them as behaviors of choice. These inaccurate perceptions trivialize what are actually serious, potentially lethal psychiatric conditions (Crisp, 2005; Crisp et al., 2000; Roehrig & McLean, 2010; Sullivan, 1995). There is little public sympathy for eating disorders due to the belief that these disorders are a choice rather than a legitimate illness (Crisp, 2005; Crisp et al., 2000). Roehrig and McLean (2010) found that 50% of respondents believed it “might not be too bad” to have an eating disorder (p. 673). In the same study, some participants expressed envy of or admiration for people with eating disorders, attitudes that are nonexistent towards other mental illnesses (Roehrig & McLean, 2010). In one study, 90% of participants rated the ultimate outcome of eating disorders as good, while another found that 75% of students believed treatment would be very effective in curing anorexia nervosa (Crisp et al., 2000; Holliday, Wall, Treasure, & Weinman, 2005). In truth, professionals consider eating disorders to be chronic conditions, frequently with poor outcomes (Klein & Walsh, 2003; Sullivan, 1995). At this time, there is no evidence-based treatment for anorexia nervosa (Fairburn, 2005). Considering the painful and invalidating nature of eating disorder stereotypes, it is unsurprising that people with eating disorders may be hesitant to disclose their condition. Those with eating disorders who attempt to conceal their illness may isolate themselves from friends and family who could help and support them, and they often do not seek treatment due to fear of stigma. Research has demonstrated that stigma and stereotypes about eating disorders are significant barriers to care (Becker, Arrindell, Perloe, Fay, & Striegel-Moore 2010; Becker, Franko, Speck, & Herzog, 2003; Roehrig & McLean, 2010; Stewart et al., 2006). In previous studies, knowing someone with an eating disorder had a moderating effect on stigma, indicating that familiarity with eating disorders reduces stigma (Crisp, 2005; Crisp et al., 2000; Roehrig & McLean, 2010;
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Stewart, Schiavo, Herzog, & Franko, 2008). It is believed that education has the power to reduce stigma (Crisp, 2005). Awareness and education campaigns have been conducted in an attempt to dispel the stigma and stereotypes surrounding eating disorders. These campaigns have shown promise in stigma reduction in members of the general public as well as more specialized groups such as college students (Crisafulli et al., 2008, 2010; Crisp, 2005). Medical professionals are an important, but often overlooked, target of anti-stigma campaigns. After all, they are the first line of defense in diagnosing patients with eating disorders and in referring them to specialized treatment when necessary. Those who believe eating disorders only occur in young, white females inadvertently prevent patients who do not fit this stereotype from seeking treatment (Becker et al., 2003, 2010; Evans et al., 2011; Soban, 2006). Eating disorders are under-diagnosed in males and minorities, so education that eating disorders occur across genders and ethnic groups is warranted (Wingfield, Kelly, Serdar, Shivy, & Mazzeo, 2011). Awareness and education programs for medical professionals, such as multi-professional conferences and specialized training and supervision, have been implemented in some areas, but they are not a common practice (Buhl, 1993). Medical professionals as a group have enormous power to break down stigma by treating patients with stigmatized identities with acceptance (Stewart et al., 2006). Accounts of nurses working in eating disorder programs attest to the important role of nurses in working with patients with eating disorders and emphasize the importance of building accepting, caring relationships with these patients (Newell, 2004; Ryan, Malson, Clarke, Anderson, & Kohn, 2006; Snell, Crowe, & Jordan, 2010). Nurses who treat patients with eating disorders with empathy and respect build bridges which may empower patients to see themselves as more than their disease. Anti-stigma and awareness campaigns targeted toward nurses could greatly benefit individuals with eating disorders. Effective campaigns to reduce stigma depend on understanding the nature and characteristics of stigmatizing attitudes (Roehrig & McLean, 2010). This study evaluates nursing students’ adherence to stereotypes and stigmatizing attitudes about eating disorders before and after a week-long eating disorders awareness intervention. Results will indicate which beliefs are endorsed by nursing students (advisable campaign targets) and test the ability of a short-term intervention to reduce these beliefs.
METHOD Participants Participants were (n = 131) female, undergraduate nursing students enrolled at the University of Saint Joseph in the Spring 2014 semester. Participants
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were recruited via solicitation in their nursing courses. No compensation was offered. Based upon self-report, the sample was 86% Caucasian. Participant age ranged from 19 to 42 years of age with a median of 21 years. Ninety percent of participants were between the ages of 19 and 24. Class years represented were: sophomore (36%), junior (31%), and senior (33%). Of all participants, 64% reported knowing at least one person with an eating disorder, and 46% reported knowing two or more.
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Materials The Alliance for Eating Disorders Awareness supplied informational brochures and awareness posters reporting key statistics used to target stereotypes about eating disorders. Brochures were: “What Are Eating Disorders?” “What is Anorexia Nervosa?” “What is Bulimia Nervosa,” “What is Binge Eating Disorder,” and “For Friends and Family.” Poster messages were: “Anorexia has the highest mortality rate among all psychological disorders,” “1 in 4 individuals with eating disorders are male,” “10% of eating disorder patients are children under the age of 10,” “Eating disorders do not discriminate by age, race, class, or gender,” “The most rapidly growing group of individuals with eating disorders is women in mid-life,” and “The risk of developing an eating disorder is 50–80% determined by genetics.” Additionally, posted helpline flyers read: “Struggling with an eating disorder? Worried about a friend or family member? Help is available. Recovery is possible.” Examples of brochures and posters can be obtained by request from the authors or the Alliance for Eating Disorders Awareness. Approximately 60 posters and flyers were displayed in total. Opinions questionnaire. Participants’ beliefs and attitudes towards individuals with eating disorders were assessed using questionnaire items adapted from previous studies of the stigmatization of eating disorders (Crisafulli et al., 2008; Crisp et al., 2000; Stewart et al., 2006). Participants were asked to rate on a 7-point Likert scale, ranging from 1 (completely disagree) to 7 (completely agree) the extent to which they agreed or disagreed with each item of a list of statements about people with eating disorders. The scale consisted of four statements reflecting various aspects of stigma towards eating disorders: beliefs about volition, responsibility, and legitimacy as serious mental illnesses, for example. The items read, they [people with eating disorders]: are to blame for their condition, could pull themselves together if they wanted to, are acting this way to get attention, would not improve with treatment, and will never fully recover. Stereotypes questionnaire. Three items reflecting inaccurate, stereotypical beliefs (people with eating disorders are almost always women, people with eating disorders are almost always between the ages of 18 and 24, and their condition puts their lives at risk) were added for the purposes of this
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study. These last three items were specifically addressed by the on-campus intervention. Causes of eating disorders. Participants’ beliefs about the causal factors of eating disorders were assessed with a 4-item questionnaire adapted from previous studies measuring beliefs about the causes of anorexia nervosa (Crisfulli et al., 2008; Stewart et al., 2006). The items were edited to ask about eating disorders in general, rather than anorexia nervosa specifically. Participants were asked to rate on a 5-point Likert scale, ranging from 1 (not at all) to 5 (completely) the extent to which they believed each factor contributes to the development of an eating disorder. The factors were: lack of social support, biological/genetic factors, society’s thin ideal, and vanity. One of these items, biological/genetic factors, was promoted through the awareness intervention.
Procedure This research was reviewed and approved by the Institutional Review Board of the University of Saint Joseph. Participants were approached twice over the course of the study in order to complete a survey regarding their beliefs about people with eating disorders. They completed the same questionnaire on both occasions. The pre-test was followed by a passive, week-long eating disorders awareness intervention consisting of on-campus posters, flyers, and information tables. The posters were placed on campus bulletin boards and in bathrooms, stairwells, hallways, and classrooms. Information tables were placed in the two main academic buildings on campus and in the student union. The information presented was designed to combat stereotypes about eating disorders (see Materials). The campaign was campus-wide; it did not actively target study participants. One week after the intervention, participants completed the post-test. Participants were encouraged, but not required, to complete both surveys. There was notable attrition (pre-test n = 131, post-test n = 79).
RESULTS A multiple analysis of variance (MANOVA) was conducted for each set of dependent variables (Opinions, Stereotypes, and Causes). All MANOVAs used the same independent variables: test condition (pretest and post-test) and knowing someone with an eating disorder (no or yes). For the opinions measure, the MANOVA included the dependent variables: Blame, Attention, Not Improve, and Never Recover. The dependent variables of the stereotypes measure were: Women, Age 13–24, and Risk Life. The MANOVA for the causes scale included the items: Lack of Support, Biogenetic Factors, Society’s Thin Ideal, and Vanity as dependent variables. Analyses explored main effects and interaction effects.
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Multivariate tests indicated that there were no significant main effects of test condition on the combined dependent variable of opinions about people with eating disorders. F(4,199) = 0.782, Wilks’ Lambda = 0.985, p = .538, η2 = 0.015. There were no significant main effects of knowing someone with an eating disorder on the combined dependent variable of opinions about people with eating disorders. F(4,199) = 0.759, Wilks’ Lambda = 0.985, p = .553, η2 = 0.015. There was a significant interaction effect of test condition and knowing someone with an eating disorder on the combined dependent variable of opinions about people with eating disorders. F(4,199) = 3.316, Wilks’ Lambda = .938, p = .012, η2 = 0.062. An analysis of each individual dependent variable using a Bonferroni adjusted alpha level of 0.013 found that the effect was driven by the variable “People with eating disorders would not improve with treatment,” F(1,202) = 11.459, p = .001, η2 = 0.054. For this variable, the mean score of participants who did not know someone with an eating disorder fell from 2.13 (SD = 1.358) in the pre-test to 1.57 (SD = 0.590) in the post-test. The mean score of participants who knew someone with an eating disorder rose from 1.64 (SD = 0.786) in the pre-test to 2.22 (SD = 1.383) in the post-test (see Figure 1). This indicates that the eating disorders awareness intervention led to a belief amongst participants who did not know someone with an eating disorder that people with eating disorders were more likely to improve with treatment. Post-intervention, participants
7 Mean Score (Disagree - Agree)
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Opinions Questionnaire
6 5 Know ED No Yes
4 3 2 1
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Post-Test
FIGURE 1 Interaction effect of test condition and knowing someone with an eating disorder on the belief that people with eating disorders would not improve with treatment. The mean score of participants who did not know someone with an eating disorder decreased from pre-test to post-test (more likely to improve), and the mean score of participants who knew someone with an eating disorder increased from pre-test to post-test on this item (less likely to improve).
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who knew someone with an eating disorder believed that people with eating disorders were less likely to improve with treatment. There was no significant effect from the other variables of the opinions scale: “People with eating disorders is to blame for their own condition” (F(1,202) = 0.653, p = .420, η2 = 0.003), “People with eating disorders are using their condition to seek attention,” (F(1,202) = 2.013, p = .157, η2 = 0.010), and “People with eating disorders will never recover,” (F(1,202) = 0.826, p = .365, η2 = 0.004).
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Stereotypes Questionnaire Multivariate tests indicated that there was a significant main effect of test condition on the combined dependent variable of stereotypes about people with eating disorders. F(3,201) = 2.680, Wilks’ Lambda = 0.962, p = .048, η2 = 0.038. An analysis of each individual dependent variable using a Bonferroni adjusted alpha level of 0.017 indicated that the effect was driven by a significant effect of test condition on the belief that people with eating disorders are almost always women, F(1,203) = 5.917, p = .016, η2 = 0.028. The mean score of participants fell from 3.80 (SD = 1.568) in the pre-test to 3.35 (SD = 1.626) in the post-test. After the intervention, participants were less likely to subscribe to the stereotypical belief that people with eating disorders are almost always women. The main effect of test condition on the belief that people with eating disorders are almost always between the ages of 13 and 24 was not significant, F(1,203) = 0.174, p = .677. The main effect of test condition on the belief that the condition of people with eating disorders puts their lives at risk was not significant, F(1,203) = 0.006, p = .940. There were no significant main effects of knowing someone with an eating disorder on the combined dependent variable of stereotypes about people with eating disorders, F(3,201) = 1.385, Wilks’ Lambda = 0.980, p = .249, η2 = 0.020. There was a significant interaction effect of test condition and knowing someone with an eating disorder on the combined dependent variable of stereotypes about people with eating disorders, F(3,201) = 4.657, Wilks’ Lambda = 0.935, p = .004, η2 = 0.065. An analysis of each individual dependent variable using a Bonferroni adjusted alpha level of 0.017 indicated that the effect was driven by a significant interaction effect on the variable “The condition of people with eating disorders puts their lives at risk”, F(1,203) = 7.997, p = .005, η2 = 0.038. The mean score on this item for participants who did not know someone with an eating disorder rose from 6.09 (SD = 1.411) in the pre-test to 6.58 (SD = 0.929) in the post-test (see Figure 2). This suggests that, after the intervention, these participants believed more strongly that people with eating disorders were putting their lives at risk. The mean score on this item for participants who knew someone with an eating disorder fell from 6.54 (SD = 0.754) in the pre-test to 6.02 (SD = 1.536) in the
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Mean Score (Disagree - Agree)
7 6 5
Yes 3 2 1
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Know ED No
4
Pre-Test
Post-Test
FIGURE 2 Interaction effect of test condition and knowing someone with an eating disorder on the belief that the condition of people with eating disorders puts their lives at risk. The mean score of participants who did not know someone with an eating disorder increased from pre-test to post-test (more likely putting their lives at risk), and the mean score of participants who knew someone with an eating disorder decreased from pre-test to post-test on this item (less likely putting their lives at risk).
post-test (see Figure 2). This suggests that, after the intervention, these participants believed less strongly that people with eating disorders were putting their lives at risk. The interaction effect was not significant for the belief that people with eating disorders are almost always women, F(1,203) = 2.847, p = .093, η2 = 0.014, or the belief that they are almost always between the ages of 13 and 24, F(1,203) = 1.206, p = .273, η2 = 0.006.
Causes Questionnaire Multivariate tests indicated that there was a significant main effect of test condition on the combined dependent variable of beliefs about the causes of eating disorders. F(4,200) = 3.447, Wilks’ Lambda = 0.936, p = .009, η2 = 0.064. An analysis of each individual dependent variable using a Bonferroni adjusted alpha level of 0.013 indicated that the effect was mostly driven by a significant effect of test condition on beliefs about the contribution of society’s thin ideal to the development of eating disorders, F(1,203) = 7.138, p = .008, η2 = 0.034. The mean score of participants fell from 4.24 (SD = 0.682) in the pre-test to 3.87 (SD = 0.903) in the post-test. After the intervention, participants rated society’s thin ideal as less of a contributing factor to the development of eating disorders. There was a marginal main effect of test condition on the belief that biological and genetic factors are a causal factor for eating disorders, F(1,203) = 5.863, p = .016, η2 = 0.028. The mean score for this item rose from 2.89 (SD = 0.868) in the pre-test to 3.13 (SD = 0.858) in the post-test, indicating that, after the intervention, participants endorsed biological and genetic factors more strongly as a causal
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factor for eating disorders. The main effects of test condition on ratings of lack of support and vanity as causal factors for eating disorder were not significant, F(1,203) = 1.160, p = .283, η2 = 0.006, and F(1,203) = 0.087, p = .768, η2 = 0.000, respectively. The main effect of knowing someone with an eating disorder on the combined dependent variable of beliefs about causes of eating disorders was not significant, F(4,200) = 1.805, Wilks’ Lambda = 0.965, p = .129, η2 = 0.035. The interaction effect of test condition and knowing someone with an eating disorder on the combined dependent variable of beliefs about causes of eating disorders was not significant. F(4,200) = 1.528, Wilks’ Lambda = 0.970, p = .195, η2 = 0.030.
DISCUSSION The effects of this short-term, passive intervention were encouraging. The significant effects indicated that the key messages of the campaign were internalized by study participants. Reductions in beliefs that people with eating disorders are mostly women and that eating disorders are due to society’s thin ideal, accompanied by an increased awareness of biological and genetic causes of eating disorders are desirable changes which were observed across participants. Additionally, those participants who did not know someone with an eating disorder reported increased awareness that the condition of people with eating disorders puts their lives at risk and a decrease in the belief that people with eating disorders will not improve with treatment. Effects were noted both on variables directly related to intervention messages and on variables which may indicate secondary effects. In short, the intervention was successful. More than half of the participants were commuter students, and many were not on campus every day. Seniors, in particular, only had one, onetime-a-week nursing course on campus. In addition, all grade levels had major exams during the study. Considering these factors, the students may have had little exposure to, and paid little attention to, the intervention posters. Despite this, the intervention had significant effects. A longer-term passive intervention could be even more effective. In addition to items specifically targeted by the intervention, participant responses indicated a decrease in the belief that eating disorders can be primarily attributed to society’s thin ideal. This is a heartening result, and is perhaps due to the campaign’s focus on dispelling stereotypical beliefs. Many eating disorder awareness initiatives include themes of positive body image and self-esteem. These messages in themselves are important and worthy, but they undermine the efforts of eating disorder awareness campaigns. They focus on the thin ideal, reinforcing the belief that eating disorders are
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an affliction of young women and are simply about food and weight. In contrast, this study’s messages directly counteracted the stereotypical image of eating disorders by presenting eating disorders as deadly, partially genetically based, and affecting a broad population, including men and children. It appears that raising awareness around these components of eating disorders can have secondary effects in dispelling additional stereotypes about eating disorders. Several of the measured beliefs and attitudes did not change significantly, despite the intervention. There were no significant effects on the belief that most people with eating disorders are between the ages of 13 and 24. This stereotype was addressed by two posted flyers: “10% of eating disorder patients are children under the age of 10” and “the fastest growing group of individuals with eating disorders is women in midlife.” It may be that these messages bring attention to patients of unexpected ages, but they may not change beliefs about “most” people with eating disorders. Ten percent is still a minority, and “fastest growing” does not necessarily mean the number of individuals is significant. The messages may have impacted study participants, but the use of the term “most” in the questionnaire could have masked more subtle attitudinal shifts. There were no significant changes in beliefs that eating disorders are due to a lack of support or are due to vanity, or that people with eating disorders are to blame for their condition, are using their condition to get attention, or would never recover. None of these items were specifically addressed by intervention messages, so this is not surprising. The interaction effects seen in the results require a more complex interpretation that the main effects. Post-intervention, participants who did not know someone with an eating disorder understood that eating disorders are life-threatening, but also that treatment is available, and can be helpful. Participants who knew someone with an eating disorder were influenced in the opposite direction on the same items. After the intervention, they reported beliefs that people with eating disorders were less likely to improve with treatment, but also that the condition of people with eating disorders was less life-threatening. These beliefs seem contradictory. This unexpected result could be a secondary effect of increased awareness of the prevalence of eating disorders. No one wants to believe that their friend or family member will die, so, while they appreciate that eating disorders are dangerous, these participants may interpret prevalence to mean that, with many people afflicted, their acquaintance is less likely to be one of the ones to die. Additionally, the statistic regarding mortality was specifically about anorexia nervosa, and participants’ acquaintances may have been diagnosed with one of the other eating disorders. Also, deaths of men and children as a result of an eating disorder are not often (if ever) broadcast in the media, so raising awareness of eating disorders in these groups may unintentionally reduce beliefs about fatality in eating disorders. The combined
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effects of these interpretations of the intervention’s messages could explain the post-test reduction in the belief, among participants who knew someone with an eating disorder, that eating disorders are life-threatening. If the immediate fear for an acquaintance’s life is dispelled, attention can turn from an immediate emotional response to cognitively based, long term thinking. Though they may not believe the life of the person they know is at risk, participants have still presumably seen that person struggling with their illness. It may be that eating disorders are perceived as being more difficult to treat when they are attributed to inborn traits rather than having socio-cultural roots. An increased understanding of biological and genetic factors may lead participants to feel that someone with an eating disorder has less ability to change, increasing the belief that their acquaintance will not improve with treatment. Additionally, nursing students may believe that nonmedical treatment techniques will not be effective in treating a disorder based in biology. For these nursing students, if their friend or family member has not been “cured” by their treatment, it may be perceived that the treatment has not yet, and will not, help them to improve. Passive campaigns are not usually thought of as impactful, but, counterintuitively, they may be an appropriate strategy for eating disorder awareness initiatives. Due to the stigma around eating disorders, it can be difficult to engage the public in active awareness and education events and campaigns (e.g., fundraisers, public lectures, awareness walks). Active interventions cannot be successful if people are unwilling to participate. This is not a problem for passive interventions (e.g., posters and flyers). Passive campaigns do not require people to actively engage with materials and messages. The poster intervention used here reached its target audience without bringing up defensive or avoidant reactions in observers; no one can be judged for seeing a poster. There are several potential sources of error in the methodology of this study. The sample did not include men or older women, so results may not be generalizable to all members of the medical professions. Still, nursing students were the intended population, and their responses to the intervention were significant. The loss of participants from pre-test to post-test is also important to consider. More juniors than seniors or sophomores dropped out of the study, but there were no other significant differences in demographic characteristics between pre- and post-test samples. It is possible that the participants who dropped out held different beliefs about people with eating disorders than those who completed the study. However, the standard deviations of the significant results were all greater in the post-test than the pre-test (excepting “biological and genetic factors” which changed from SD = 0.868 to SD = 0.858), so it is unlikely that a group of responses at one extreme or the other was eliminated by participant attrition. Additionally, the data were self-reported, so there is a possibility that social desirability factors influenced questionnaire answers.
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CONCLUSIONS A sample of university nursing students, when exposed to a week-long passive eating disorders intervention, exhibited significant changes in stigmatizing beliefs about people with eating disorders. These attitudinal shifts in the areas targeted by the intervention indicated that study participants engaged with the intervention and internalized its messages despite its short duration and passive nature. In the future, attention should be paid to the possibility of different interpretations of intervention messages by those who know someone with an eating disorder, in comparison to those who do not. People who know someone with an eating disorder may have a more complex interpretation of awareness messages due to an analysis of the messages in the context of their personal experience with eating disorders. Overall, the stigma and stereotype-reducing effects of this short-term, passive intervention exceeded expectations. Passive interventions may be an effective means of reaching medical professionals with messages targeting the eating disorder-related stigma and stereotypes which are currently a barrier to care for many individuals with eating disorders. Such an intervention, which is low-cost and requires few resources, holds much promise for educating important populations, such as nursing students, about eating disorders.
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Crisp, A. (2005). Stigmatization of and discrimination against people with eating disorders including a report of two nationwide surveys. European Eating Disorders Review, 13, 147–152. doi:10.1002/erv.648 Crisp, A. H., Gelder, M. G., Rix, S., Meltzer, H. I., & Rowlands, O. J. (2000). Stigmatisation of people with mental illnesses. The British Journal of Psychiatry, 177, 4–7. doi:10.1192/bjp.177.1.4 Evans, E. J., Hay, P. J., Mond, J., Paxton, S. J., Quirk, F., Rodgers, B., Jhajj, A. K., & Sawoniewska, M. A. (2011). Barriers to help-seeking in young women with eating disorders: A qualitative exploration in a longitudinal community survey. Eating Disorders, 19, 270–285. doi:10.1080/10640266.2011.566152 Fairburn, C. G. (2005). Evidence-based treatment of anorexia nervosa. International Journal of Eating Disorders, 37, S26–S30. doi:10.1002/eat.20112 Goffman, E. (1963). Stigma: Notes on the management of a spoiled identity. New York, NY: J. Aronson. Holliday, J., Wall, E., Treasure, J., & Weinman, J. (2005). Perceptions of illness in individuals with anorexia nervosa: A comparison with lay men and women. International Journal of Eating Disorders, 37, 50–56. doi:10.1002/eat.20056 Klein, D. A., & Walsh, B. T. (2003). Eating disorders. International Review of Psychiatry, 15, 205–216. doi:10.1080/0954026031000136839 Newell, C. (2004). Nursing and eating disorders. European Eating Disorders Review, 12, 1–3. doi:10.1002/erv.564 Rich, E. (2006). Anorexics dis(connection): Managing anorexia as an illness and an identity. Sociology of Health & Illness, 28, 284–305. doi: 10.1111/j.1467-9566.2006.00493.x Roehrig, J. P., & McLean, C. P. (2010). A comparison of stigma toward eating disorders versus depression. International Journal of Eating Disorders, 43, 671–674. doi:10.1002/eat.20760 Ryan, V., Malson, H., Clarke, S., Anderson, G., & Kohn, M. (2006). Discursive constructions of “eating disorders nursing”: An analysis of nurses’ accounts of nursing eating disorder patients. European Eating Disorders Review, 14, 125–135. doi:10.1002/erv.666 Snell, L., Crowe, M., & Jordan, J. (2010). Maintaining a therapeutic connection: Nursing in an inpatient eating disorder unit. Journal of Clinical Nursing, 19, 351–358. doi:10.1111/j.1365-2702.2009.03000.x Soban, C. (2006). What about the boys?: Addressing issues of masculinity within male anorexia nervosa in a feminist therapeutic environment. International Journal of Men’s Health, 5, 251–267. doi:10.3149/jmh.0503.251 Stewart, M., Keel, P. K., & Schiavo, R. (2006). Stigmatization of anorexia nervosa. International Journal of Eating Disorders, 39, 320–325. doi:10.1002/eat.20262 Stewart, M., Schiavo, R., Herzog, D. B., & Franko, D. L. (2008). Stereotypes, prejudice and discrimination of women with anorexia nervosa. European Eating Disorders Review, 16, 311–318. doi:10.1002/erv.849 Sullivan, P. (1995). Mortality in anorexia nervosa. American Journal of Psychiatry, 152, 1073–1074. Wingfield, N., Kelly, N., Serdar, K., Shivy, V. A., & Mazzeo, S. E. (2011). College students’ perceptions of individuals with anorexia and bulimia nervosa. International Journal of Eating Disorders, 44, 369–375. doi:10.1002/eat.20824
ISSN: 1064-0266 (Print) 1532-530X (Online) Journal homepage: http://www.tandfonline.com/loi/uedi20
Words on Walls: Passive Eating Disorder Education Mary E. Duffy & Kristin E. Henkel To cite this article: Mary E. Duffy & Kristin E. Henkel (2015): Words on Walls: Passive Eating Disorder Education, Eating Disorders, DOI: 10.1080/10640266.2015.1034054 To link to this article: http://dx.doi.org/10.1080/10640266.2015.1034054
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Date: 05 November 2015, At: 13:49
Eating Disorders, 00:1–13, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2015.1034054
Words on Walls: Passive Eating Disorder Education MARY E. DUFFY and KRISTIN E. HENKEL
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Department of Psychology, University of Saint Joseph, West Hartford, Connecticut, USA
This study examined the effect of a short-term passive intervention on nursing students’ beliefs about eating disorders (EDs). Before and after a weeklong ED education poster campaign, participants completed questionnaires assessing their attitudes about individuals with EDs. Results showed a reduction in the belief that people with EDs are almost always women, increased attribution to biological and genetic factors, and decreased attribution to society’s thin ideal. Personal connection moderated response to the items: [people with EDs] “are putting their lives at risk” and “would not improve with treatment.” This intervention shows promise for reducing ED-associated stereotype endorsement among medical professionals.
Stigma is the negative evaluation of, and attitude towards, a group on the basis of a stereotype-linked attribute of that group. Individuals with mental illness are subject to stigma, usually in relation to perceived flaws in character (Goffman, 1963). The “undesirable differentness” of stigmatized individuals becomes their defining characteristic, overriding their actual characteristics and identity, typically with negative effects (Goffman, 1963, p. 4). People with eating disorders are one such stigmatized group. Researchers have established a number of damaging, stigmatizing beliefs about individuals with eating disorders. Widespread public attitudes frame eating disorders as irrational, self-inflicted conditions (Rich, 2006). Several studies have replicated the finding that the public believes people with eating disorders are more “to blame for their condition” and more able to “pull themselves together if they wanted to” than people with other mental and physical disorders, including: asthma, depression, schizophrenia, panic
Address correspondence to Mary E. Duffy, Department of Psychology, University of Saint Joseph, 1678 Asylum Avenue, West Hartford, CT 06117, USA. E-mail: [email protected] 1
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attacks, alcoholism, or drug addiction (e.g., Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000; Roehrig & McLean, 2010; Stewart, Keel, & Schiavo, 2006). In addition, people with eating disorders are perceived to be “acting this way for attention” (Rich, 2006; Roehrig & McLean, 2010; Stewart et al. 2006). Stewart et al. (2006) explain the stereotype that eating disorders occur only in adolescent girls may contribute to beliefs that eating disorders are caused by body dissatisfaction and factors such as parenting and lack of social support. While socio-cultural factors can influence risk for disordered eating (e.g. Becker, 2004), they are not the sole causal factor. A lack of knowledge of the biological and genetic bases of anorexia nervosa may be one reason individuals with the disorder are blamed and held responsible for their condition (Crisafulli, Thompson-Brenner, Franko, Eddy, & Herzog, 2010; Crisafulli, Von Holle, Bulik, 2008). In one intervention, education about the genetic and biological causes of eating disorders reduced beliefs that eating disorders are volitional and controllable (Crisafulli et al., 2008). Overall, stigmatizing beliefs about eating disorders serve to frame them as behaviors of choice. These inaccurate perceptions trivialize what are actually serious, potentially lethal psychiatric conditions (Crisp, 2005; Crisp et al., 2000; Roehrig & McLean, 2010; Sullivan, 1995). There is little public sympathy for eating disorders due to the belief that these disorders are a choice rather than a legitimate illness (Crisp, 2005; Crisp et al., 2000). Roehrig and McLean (2010) found that 50% of respondents believed it “might not be too bad” to have an eating disorder (p. 673). In the same study, some participants expressed envy of or admiration for people with eating disorders, attitudes that are nonexistent towards other mental illnesses (Roehrig & McLean, 2010). In one study, 90% of participants rated the ultimate outcome of eating disorders as good, while another found that 75% of students believed treatment would be very effective in curing anorexia nervosa (Crisp et al., 2000; Holliday, Wall, Treasure, & Weinman, 2005). In truth, professionals consider eating disorders to be chronic conditions, frequently with poor outcomes (Klein & Walsh, 2003; Sullivan, 1995). At this time, there is no evidence-based treatment for anorexia nervosa (Fairburn, 2005). Considering the painful and invalidating nature of eating disorder stereotypes, it is unsurprising that people with eating disorders may be hesitant to disclose their condition. Those with eating disorders who attempt to conceal their illness may isolate themselves from friends and family who could help and support them, and they often do not seek treatment due to fear of stigma. Research has demonstrated that stigma and stereotypes about eating disorders are significant barriers to care (Becker, Arrindell, Perloe, Fay, & Striegel-Moore 2010; Becker, Franko, Speck, & Herzog, 2003; Roehrig & McLean, 2010; Stewart et al., 2006). In previous studies, knowing someone with an eating disorder had a moderating effect on stigma, indicating that familiarity with eating disorders reduces stigma (Crisp, 2005; Crisp et al., 2000; Roehrig & McLean, 2010;
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Stewart, Schiavo, Herzog, & Franko, 2008). It is believed that education has the power to reduce stigma (Crisp, 2005). Awareness and education campaigns have been conducted in an attempt to dispel the stigma and stereotypes surrounding eating disorders. These campaigns have shown promise in stigma reduction in members of the general public as well as more specialized groups such as college students (Crisafulli et al., 2008, 2010; Crisp, 2005). Medical professionals are an important, but often overlooked, target of anti-stigma campaigns. After all, they are the first line of defense in diagnosing patients with eating disorders and in referring them to specialized treatment when necessary. Those who believe eating disorders only occur in young, white females inadvertently prevent patients who do not fit this stereotype from seeking treatment (Becker et al., 2003, 2010; Evans et al., 2011; Soban, 2006). Eating disorders are under-diagnosed in males and minorities, so education that eating disorders occur across genders and ethnic groups is warranted (Wingfield, Kelly, Serdar, Shivy, & Mazzeo, 2011). Awareness and education programs for medical professionals, such as multi-professional conferences and specialized training and supervision, have been implemented in some areas, but they are not a common practice (Buhl, 1993). Medical professionals as a group have enormous power to break down stigma by treating patients with stigmatized identities with acceptance (Stewart et al., 2006). Accounts of nurses working in eating disorder programs attest to the important role of nurses in working with patients with eating disorders and emphasize the importance of building accepting, caring relationships with these patients (Newell, 2004; Ryan, Malson, Clarke, Anderson, & Kohn, 2006; Snell, Crowe, & Jordan, 2010). Nurses who treat patients with eating disorders with empathy and respect build bridges which may empower patients to see themselves as more than their disease. Anti-stigma and awareness campaigns targeted toward nurses could greatly benefit individuals with eating disorders. Effective campaigns to reduce stigma depend on understanding the nature and characteristics of stigmatizing attitudes (Roehrig & McLean, 2010). This study evaluates nursing students’ adherence to stereotypes and stigmatizing attitudes about eating disorders before and after a week-long eating disorders awareness intervention. Results will indicate which beliefs are endorsed by nursing students (advisable campaign targets) and test the ability of a short-term intervention to reduce these beliefs.
METHOD Participants Participants were (n = 131) female, undergraduate nursing students enrolled at the University of Saint Joseph in the Spring 2014 semester. Participants
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were recruited via solicitation in their nursing courses. No compensation was offered. Based upon self-report, the sample was 86% Caucasian. Participant age ranged from 19 to 42 years of age with a median of 21 years. Ninety percent of participants were between the ages of 19 and 24. Class years represented were: sophomore (36%), junior (31%), and senior (33%). Of all participants, 64% reported knowing at least one person with an eating disorder, and 46% reported knowing two or more.
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Materials The Alliance for Eating Disorders Awareness supplied informational brochures and awareness posters reporting key statistics used to target stereotypes about eating disorders. Brochures were: “What Are Eating Disorders?” “What is Anorexia Nervosa?” “What is Bulimia Nervosa,” “What is Binge Eating Disorder,” and “For Friends and Family.” Poster messages were: “Anorexia has the highest mortality rate among all psychological disorders,” “1 in 4 individuals with eating disorders are male,” “10% of eating disorder patients are children under the age of 10,” “Eating disorders do not discriminate by age, race, class, or gender,” “The most rapidly growing group of individuals with eating disorders is women in mid-life,” and “The risk of developing an eating disorder is 50–80% determined by genetics.” Additionally, posted helpline flyers read: “Struggling with an eating disorder? Worried about a friend or family member? Help is available. Recovery is possible.” Examples of brochures and posters can be obtained by request from the authors or the Alliance for Eating Disorders Awareness. Approximately 60 posters and flyers were displayed in total. Opinions questionnaire. Participants’ beliefs and attitudes towards individuals with eating disorders were assessed using questionnaire items adapted from previous studies of the stigmatization of eating disorders (Crisafulli et al., 2008; Crisp et al., 2000; Stewart et al., 2006). Participants were asked to rate on a 7-point Likert scale, ranging from 1 (completely disagree) to 7 (completely agree) the extent to which they agreed or disagreed with each item of a list of statements about people with eating disorders. The scale consisted of four statements reflecting various aspects of stigma towards eating disorders: beliefs about volition, responsibility, and legitimacy as serious mental illnesses, for example. The items read, they [people with eating disorders]: are to blame for their condition, could pull themselves together if they wanted to, are acting this way to get attention, would not improve with treatment, and will never fully recover. Stereotypes questionnaire. Three items reflecting inaccurate, stereotypical beliefs (people with eating disorders are almost always women, people with eating disorders are almost always between the ages of 18 and 24, and their condition puts their lives at risk) were added for the purposes of this
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study. These last three items were specifically addressed by the on-campus intervention. Causes of eating disorders. Participants’ beliefs about the causal factors of eating disorders were assessed with a 4-item questionnaire adapted from previous studies measuring beliefs about the causes of anorexia nervosa (Crisfulli et al., 2008; Stewart et al., 2006). The items were edited to ask about eating disorders in general, rather than anorexia nervosa specifically. Participants were asked to rate on a 5-point Likert scale, ranging from 1 (not at all) to 5 (completely) the extent to which they believed each factor contributes to the development of an eating disorder. The factors were: lack of social support, biological/genetic factors, society’s thin ideal, and vanity. One of these items, biological/genetic factors, was promoted through the awareness intervention.
Procedure This research was reviewed and approved by the Institutional Review Board of the University of Saint Joseph. Participants were approached twice over the course of the study in order to complete a survey regarding their beliefs about people with eating disorders. They completed the same questionnaire on both occasions. The pre-test was followed by a passive, week-long eating disorders awareness intervention consisting of on-campus posters, flyers, and information tables. The posters were placed on campus bulletin boards and in bathrooms, stairwells, hallways, and classrooms. Information tables were placed in the two main academic buildings on campus and in the student union. The information presented was designed to combat stereotypes about eating disorders (see Materials). The campaign was campus-wide; it did not actively target study participants. One week after the intervention, participants completed the post-test. Participants were encouraged, but not required, to complete both surveys. There was notable attrition (pre-test n = 131, post-test n = 79).
RESULTS A multiple analysis of variance (MANOVA) was conducted for each set of dependent variables (Opinions, Stereotypes, and Causes). All MANOVAs used the same independent variables: test condition (pretest and post-test) and knowing someone with an eating disorder (no or yes). For the opinions measure, the MANOVA included the dependent variables: Blame, Attention, Not Improve, and Never Recover. The dependent variables of the stereotypes measure were: Women, Age 13–24, and Risk Life. The MANOVA for the causes scale included the items: Lack of Support, Biogenetic Factors, Society’s Thin Ideal, and Vanity as dependent variables. Analyses explored main effects and interaction effects.
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Multivariate tests indicated that there were no significant main effects of test condition on the combined dependent variable of opinions about people with eating disorders. F(4,199) = 0.782, Wilks’ Lambda = 0.985, p = .538, η2 = 0.015. There were no significant main effects of knowing someone with an eating disorder on the combined dependent variable of opinions about people with eating disorders. F(4,199) = 0.759, Wilks’ Lambda = 0.985, p = .553, η2 = 0.015. There was a significant interaction effect of test condition and knowing someone with an eating disorder on the combined dependent variable of opinions about people with eating disorders. F(4,199) = 3.316, Wilks’ Lambda = .938, p = .012, η2 = 0.062. An analysis of each individual dependent variable using a Bonferroni adjusted alpha level of 0.013 found that the effect was driven by the variable “People with eating disorders would not improve with treatment,” F(1,202) = 11.459, p = .001, η2 = 0.054. For this variable, the mean score of participants who did not know someone with an eating disorder fell from 2.13 (SD = 1.358) in the pre-test to 1.57 (SD = 0.590) in the post-test. The mean score of participants who knew someone with an eating disorder rose from 1.64 (SD = 0.786) in the pre-test to 2.22 (SD = 1.383) in the post-test (see Figure 1). This indicates that the eating disorders awareness intervention led to a belief amongst participants who did not know someone with an eating disorder that people with eating disorders were more likely to improve with treatment. Post-intervention, participants
7 Mean Score (Disagree - Agree)
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Opinions Questionnaire
6 5 Know ED No Yes
4 3 2 1
Pre-Test
Post-Test
FIGURE 1 Interaction effect of test condition and knowing someone with an eating disorder on the belief that people with eating disorders would not improve with treatment. The mean score of participants who did not know someone with an eating disorder decreased from pre-test to post-test (more likely to improve), and the mean score of participants who knew someone with an eating disorder increased from pre-test to post-test on this item (less likely to improve).
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who knew someone with an eating disorder believed that people with eating disorders were less likely to improve with treatment. There was no significant effect from the other variables of the opinions scale: “People with eating disorders is to blame for their own condition” (F(1,202) = 0.653, p = .420, η2 = 0.003), “People with eating disorders are using their condition to seek attention,” (F(1,202) = 2.013, p = .157, η2 = 0.010), and “People with eating disorders will never recover,” (F(1,202) = 0.826, p = .365, η2 = 0.004).
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Stereotypes Questionnaire Multivariate tests indicated that there was a significant main effect of test condition on the combined dependent variable of stereotypes about people with eating disorders. F(3,201) = 2.680, Wilks’ Lambda = 0.962, p = .048, η2 = 0.038. An analysis of each individual dependent variable using a Bonferroni adjusted alpha level of 0.017 indicated that the effect was driven by a significant effect of test condition on the belief that people with eating disorders are almost always women, F(1,203) = 5.917, p = .016, η2 = 0.028. The mean score of participants fell from 3.80 (SD = 1.568) in the pre-test to 3.35 (SD = 1.626) in the post-test. After the intervention, participants were less likely to subscribe to the stereotypical belief that people with eating disorders are almost always women. The main effect of test condition on the belief that people with eating disorders are almost always between the ages of 13 and 24 was not significant, F(1,203) = 0.174, p = .677. The main effect of test condition on the belief that the condition of people with eating disorders puts their lives at risk was not significant, F(1,203) = 0.006, p = .940. There were no significant main effects of knowing someone with an eating disorder on the combined dependent variable of stereotypes about people with eating disorders, F(3,201) = 1.385, Wilks’ Lambda = 0.980, p = .249, η2 = 0.020. There was a significant interaction effect of test condition and knowing someone with an eating disorder on the combined dependent variable of stereotypes about people with eating disorders, F(3,201) = 4.657, Wilks’ Lambda = 0.935, p = .004, η2 = 0.065. An analysis of each individual dependent variable using a Bonferroni adjusted alpha level of 0.017 indicated that the effect was driven by a significant interaction effect on the variable “The condition of people with eating disorders puts their lives at risk”, F(1,203) = 7.997, p = .005, η2 = 0.038. The mean score on this item for participants who did not know someone with an eating disorder rose from 6.09 (SD = 1.411) in the pre-test to 6.58 (SD = 0.929) in the post-test (see Figure 2). This suggests that, after the intervention, these participants believed more strongly that people with eating disorders were putting their lives at risk. The mean score on this item for participants who knew someone with an eating disorder fell from 6.54 (SD = 0.754) in the pre-test to 6.02 (SD = 1.536) in the
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Mean Score (Disagree - Agree)
7 6 5
Yes 3 2 1
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Know ED No
4
Pre-Test
Post-Test
FIGURE 2 Interaction effect of test condition and knowing someone with an eating disorder on the belief that the condition of people with eating disorders puts their lives at risk. The mean score of participants who did not know someone with an eating disorder increased from pre-test to post-test (more likely putting their lives at risk), and the mean score of participants who knew someone with an eating disorder decreased from pre-test to post-test on this item (less likely putting their lives at risk).
post-test (see Figure 2). This suggests that, after the intervention, these participants believed less strongly that people with eating disorders were putting their lives at risk. The interaction effect was not significant for the belief that people with eating disorders are almost always women, F(1,203) = 2.847, p = .093, η2 = 0.014, or the belief that they are almost always between the ages of 13 and 24, F(1,203) = 1.206, p = .273, η2 = 0.006.
Causes Questionnaire Multivariate tests indicated that there was a significant main effect of test condition on the combined dependent variable of beliefs about the causes of eating disorders. F(4,200) = 3.447, Wilks’ Lambda = 0.936, p = .009, η2 = 0.064. An analysis of each individual dependent variable using a Bonferroni adjusted alpha level of 0.013 indicated that the effect was mostly driven by a significant effect of test condition on beliefs about the contribution of society’s thin ideal to the development of eating disorders, F(1,203) = 7.138, p = .008, η2 = 0.034. The mean score of participants fell from 4.24 (SD = 0.682) in the pre-test to 3.87 (SD = 0.903) in the post-test. After the intervention, participants rated society’s thin ideal as less of a contributing factor to the development of eating disorders. There was a marginal main effect of test condition on the belief that biological and genetic factors are a causal factor for eating disorders, F(1,203) = 5.863, p = .016, η2 = 0.028. The mean score for this item rose from 2.89 (SD = 0.868) in the pre-test to 3.13 (SD = 0.858) in the post-test, indicating that, after the intervention, participants endorsed biological and genetic factors more strongly as a causal
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factor for eating disorders. The main effects of test condition on ratings of lack of support and vanity as causal factors for eating disorder were not significant, F(1,203) = 1.160, p = .283, η2 = 0.006, and F(1,203) = 0.087, p = .768, η2 = 0.000, respectively. The main effect of knowing someone with an eating disorder on the combined dependent variable of beliefs about causes of eating disorders was not significant, F(4,200) = 1.805, Wilks’ Lambda = 0.965, p = .129, η2 = 0.035. The interaction effect of test condition and knowing someone with an eating disorder on the combined dependent variable of beliefs about causes of eating disorders was not significant. F(4,200) = 1.528, Wilks’ Lambda = 0.970, p = .195, η2 = 0.030.
DISCUSSION The effects of this short-term, passive intervention were encouraging. The significant effects indicated that the key messages of the campaign were internalized by study participants. Reductions in beliefs that people with eating disorders are mostly women and that eating disorders are due to society’s thin ideal, accompanied by an increased awareness of biological and genetic causes of eating disorders are desirable changes which were observed across participants. Additionally, those participants who did not know someone with an eating disorder reported increased awareness that the condition of people with eating disorders puts their lives at risk and a decrease in the belief that people with eating disorders will not improve with treatment. Effects were noted both on variables directly related to intervention messages and on variables which may indicate secondary effects. In short, the intervention was successful. More than half of the participants were commuter students, and many were not on campus every day. Seniors, in particular, only had one, onetime-a-week nursing course on campus. In addition, all grade levels had major exams during the study. Considering these factors, the students may have had little exposure to, and paid little attention to, the intervention posters. Despite this, the intervention had significant effects. A longer-term passive intervention could be even more effective. In addition to items specifically targeted by the intervention, participant responses indicated a decrease in the belief that eating disorders can be primarily attributed to society’s thin ideal. This is a heartening result, and is perhaps due to the campaign’s focus on dispelling stereotypical beliefs. Many eating disorder awareness initiatives include themes of positive body image and self-esteem. These messages in themselves are important and worthy, but they undermine the efforts of eating disorder awareness campaigns. They focus on the thin ideal, reinforcing the belief that eating disorders are
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an affliction of young women and are simply about food and weight. In contrast, this study’s messages directly counteracted the stereotypical image of eating disorders by presenting eating disorders as deadly, partially genetically based, and affecting a broad population, including men and children. It appears that raising awareness around these components of eating disorders can have secondary effects in dispelling additional stereotypes about eating disorders. Several of the measured beliefs and attitudes did not change significantly, despite the intervention. There were no significant effects on the belief that most people with eating disorders are between the ages of 13 and 24. This stereotype was addressed by two posted flyers: “10% of eating disorder patients are children under the age of 10” and “the fastest growing group of individuals with eating disorders is women in midlife.” It may be that these messages bring attention to patients of unexpected ages, but they may not change beliefs about “most” people with eating disorders. Ten percent is still a minority, and “fastest growing” does not necessarily mean the number of individuals is significant. The messages may have impacted study participants, but the use of the term “most” in the questionnaire could have masked more subtle attitudinal shifts. There were no significant changes in beliefs that eating disorders are due to a lack of support or are due to vanity, or that people with eating disorders are to blame for their condition, are using their condition to get attention, or would never recover. None of these items were specifically addressed by intervention messages, so this is not surprising. The interaction effects seen in the results require a more complex interpretation that the main effects. Post-intervention, participants who did not know someone with an eating disorder understood that eating disorders are life-threatening, but also that treatment is available, and can be helpful. Participants who knew someone with an eating disorder were influenced in the opposite direction on the same items. After the intervention, they reported beliefs that people with eating disorders were less likely to improve with treatment, but also that the condition of people with eating disorders was less life-threatening. These beliefs seem contradictory. This unexpected result could be a secondary effect of increased awareness of the prevalence of eating disorders. No one wants to believe that their friend or family member will die, so, while they appreciate that eating disorders are dangerous, these participants may interpret prevalence to mean that, with many people afflicted, their acquaintance is less likely to be one of the ones to die. Additionally, the statistic regarding mortality was specifically about anorexia nervosa, and participants’ acquaintances may have been diagnosed with one of the other eating disorders. Also, deaths of men and children as a result of an eating disorder are not often (if ever) broadcast in the media, so raising awareness of eating disorders in these groups may unintentionally reduce beliefs about fatality in eating disorders. The combined
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effects of these interpretations of the intervention’s messages could explain the post-test reduction in the belief, among participants who knew someone with an eating disorder, that eating disorders are life-threatening. If the immediate fear for an acquaintance’s life is dispelled, attention can turn from an immediate emotional response to cognitively based, long term thinking. Though they may not believe the life of the person they know is at risk, participants have still presumably seen that person struggling with their illness. It may be that eating disorders are perceived as being more difficult to treat when they are attributed to inborn traits rather than having socio-cultural roots. An increased understanding of biological and genetic factors may lead participants to feel that someone with an eating disorder has less ability to change, increasing the belief that their acquaintance will not improve with treatment. Additionally, nursing students may believe that nonmedical treatment techniques will not be effective in treating a disorder based in biology. For these nursing students, if their friend or family member has not been “cured” by their treatment, it may be perceived that the treatment has not yet, and will not, help them to improve. Passive campaigns are not usually thought of as impactful, but, counterintuitively, they may be an appropriate strategy for eating disorder awareness initiatives. Due to the stigma around eating disorders, it can be difficult to engage the public in active awareness and education events and campaigns (e.g., fundraisers, public lectures, awareness walks). Active interventions cannot be successful if people are unwilling to participate. This is not a problem for passive interventions (e.g., posters and flyers). Passive campaigns do not require people to actively engage with materials and messages. The poster intervention used here reached its target audience without bringing up defensive or avoidant reactions in observers; no one can be judged for seeing a poster. There are several potential sources of error in the methodology of this study. The sample did not include men or older women, so results may not be generalizable to all members of the medical professions. Still, nursing students were the intended population, and their responses to the intervention were significant. The loss of participants from pre-test to post-test is also important to consider. More juniors than seniors or sophomores dropped out of the study, but there were no other significant differences in demographic characteristics between pre- and post-test samples. It is possible that the participants who dropped out held different beliefs about people with eating disorders than those who completed the study. However, the standard deviations of the significant results were all greater in the post-test than the pre-test (excepting “biological and genetic factors” which changed from SD = 0.868 to SD = 0.858), so it is unlikely that a group of responses at one extreme or the other was eliminated by participant attrition. Additionally, the data were self-reported, so there is a possibility that social desirability factors influenced questionnaire answers.
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M. E. Duffy and K. E. Henkel
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CONCLUSIONS A sample of university nursing students, when exposed to a week-long passive eating disorders intervention, exhibited significant changes in stigmatizing beliefs about people with eating disorders. These attitudinal shifts in the areas targeted by the intervention indicated that study participants engaged with the intervention and internalized its messages despite its short duration and passive nature. In the future, attention should be paid to the possibility of different interpretations of intervention messages by those who know someone with an eating disorder, in comparison to those who do not. People who know someone with an eating disorder may have a more complex interpretation of awareness messages due to an analysis of the messages in the context of their personal experience with eating disorders. Overall, the stigma and stereotype-reducing effects of this short-term, passive intervention exceeded expectations. Passive interventions may be an effective means of reaching medical professionals with messages targeting the eating disorder-related stigma and stereotypes which are currently a barrier to care for many individuals with eating disorders. Such an intervention, which is low-cost and requires few resources, holds much promise for educating important populations, such as nursing students, about eating disorders.
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