Over the years, I have read a number of articles describing eating disorder prevention programs. Unfortunately, many reveal limited efficacy, and some even highlight detrimental effects. Primary among concerns of those evaluating prevention programs is that even when effective, we often have limited data about the long-term effects of prevention programs. This lack of follow-up limits the ability to draw conclusions about these initiatives and is cause for pause for those interested in implementing strategies to prevent eating disorders.
Further, there is some debate about whether eating disorders are even really “preventable.” Given our understanding of the complex etiology of these disorders, “prevention” can be a loaded word. The nature of the proposed intervention will undoubtedly be heavily swayed toward whichever factor(s) the program’s designer feels is most important in “causing” or contributing to disordered eating (i.e., Is the program tailored toward media awareness? Nutrition? Body image?)
I approached a recent article by Gonzalez et al. (2012) with these reservations in mind, but optimistic about the authors’ use of a longer-term follow up design. The article details results from a long-term (30 month) follow-up qualitative study with a subset of school-aged girls who had participated in a larger-scale evaluation of an eating disorder prevention program.
The authors sought to determine whether participants perceived this media literacy-based program to be helpful and personally salient. Prior quantitative analysis (Gonzalez et al., 2011) had revealed:
- Reduced self-report disordered eating attitudes
- Reduced self-report thin-ideal internalization
Building on these encouraging results, the authors interviewed 12 girls (out of an initial sample of 254) about the program and its impact on their lives. The initial intervention study was comprised of 2 experimental conditions and one control condition at 7 schools. Four girls from each condition and approximately evenly distributed according to type of school (state or subsidized) and highest/lowest eating attitudes and thin-ideal internalization were chosen for this in-depth follow-up study.
These girls were interviewed, and the authors used thematic analysis informed by Interpretative Phenomenological Analysis (IPA; Smith & Osborn, 2004) to analyze transcripts. This methodology looks to explore ways of knowing; in other words, researchers using this technique seek to learn more about participants’ subjective experiences and how they think about these experiences.
As I previously mentioned, any intervention program will be oriented toward a particular understanding of the factors that contribute to the development and maintenance of eating disorders. This program was designed with an adolescent population in mind, and is linked to 2 specific theoretical perspectives:
- Social cognitive model (Bandura, 1986): this theory argues that people act in a certain way based on their attitude toward the behaviour and the confidence they have in enacting the behaviour
- Media literacy perspective (Levine & Smolack, 2006): this perspective asserts that the media exerts a great deal of pressure on the degree to which individuals internalize thinness ideals and thus that it is important to question the content and framing of media imagery
The program had two main components:
- Nutrition Knowledge (NUT): designed to “correct false beliefs about nutrition” through education
- Media Literacy (ML): wherein students learn to critique aesthetic ideals
The 4-5 week program is described as interactive and participant-focused, and comprised:
- A PowerPoint multimedia display
- 3 sessions combined with 2 activities
- Tasks between sessions
The study was quasi-experimental (“quasi-experimental” as there were control groups, but these were not randomly assigned). In the initial intervention, students were assigned to ML, ML+NUT, or control group (CG) conditions.
The authors found 13 major themes in the girls’ responses to questions related to food, weight, shape, media, and the prevention program:
WHAT DOES THIS MEAN FOR PROGRAM EFFECTIVENESS?
Overall, authors note that both intervention groups (ML and ML+NUT) left the program with similar perceptions and learned similar things. However, I found that the authors understated the similarities between the control group participants and intervention participants. While the sample size is too small (only four from each group) to make a meaningful comparison in terms of thought and behaviour change, it is interesting that control group participants were able to come to similar conclusions in terms of the impact of media images on weight and shape concerns.
This article is also somewhat limited in terms of its implications for the development of eating disorders themselves. As we know, not everyone who holds negative perceptions about themselves develops an eating disorder. Further, being able to identify the unrealistic nature of media images does not necessarily mean that one becomes immune to them.
As the Gonzalez et al. (2011) article describing the quantitative findings reveals, participants in both conditions (ML and ML+NUT) had significantly lower scores on measures assessing eating attitudes (Eating Attitudes Test) and aesthetic body ideal influences. Thus, if we are using a model of eating disorder etiology that hinges on thin-ideal internalization and eating disorder attitudes, the program would appear to be relatively effective in reducing risk factors for eating disorders.
The qualitative analysis seems to be somewhat of an add-on, which, while it reveals interesting information about how young people conceptualize the mediatized world around them, does little to demonstrate the program’s efficacy. This is a rare instance in which I (as a qualitative researcher) would think that the quantitative data would tell us more useful information.
Where I do see this analysis as effective, however, is in its consideration of what young people want to see in an intervention. For this reason, the last theme, “Weight Related Problem Prevention and the Prevention Program,” is to me the most important. Half the battle of school-based problems is piquing and retaining the interest of students, so it makes sense to me to ask the students what they want to see, and then couple this information with sound theoretical knowledge of prevention programs to deliver the most effective program.
Ultimately, I remain cautious about the potential of prevention programs. Personally, I’m unsure whether there is anything that could have “prevented” my eating disorder, but maybe I’m wrong!
I’m curious as to whether any readers’ schools followed any kind of media-literacy and/or eating disorder prevention programs, and whether these seemed at all helpful? How do you feel about prevention programs?
González, M.L., Mora, M., Penelo, E., Goddard, E., Treasure, J., & Raich, R.M. (2012). Qualitative findings in a long-term disordered eating prevention programme follow-up with school-going girls. Journal of Health Psychology, 19 (4), 587-598 DOI: 10.1177/1359105312437433