National Eating Disorder Awareness Week came and went (in the US, anyway). Posters were shared, liked, and tweeted. Pretty (but often misguided) infographics made the rounds on the internet. Local ED groups visited schools and college campuses to educate students about eating disorders. To, you know, increase awareness.
The thing is, awareness is not always a good thing. For one, as Carrie over at ED Bites mentioned, there’s a whole lot of misinformation masquerading as fact. And two, awareness campaigns, even when the information in them is correct, may have unintended consequences, like, for example, increasing stigma or self-stigma.
Moreover, not all approaches to increasing awareness or decreasing stigma are equally effective, and the effectiveness of a particular approach may differ depending on the population studied.
So, what about the effectiveness of EDAW? In 2012, Kathleen Tillman and colleagues published a study looking at the impact of a “campus-wide, week-long series of psycho-educational and awareness program designed for National Eating Disorders Awareness Week.”
In particular, they assessed individuals’ willingness to seek help, their levels of stigma about body image and eating disorders, and their knowledge of relevant campus resources.
They compared students who attended the campus programming (161 students) to those who did not (121 students). The majority (82%) of the participants were women.
The EDAW programming entailed:
. . . A vigil for people with eating disorders, a fair to raise awareness about body image and eating disorders, a documentary film screening (Do I Look Fat?) followed by a discussion with the filmmaker, caricature drawings to raise awareness of body image issues, student-written plays performed in residence halls across campus, a professional theater show (Size Ate), and slam poetry readings focused on raising awareness of body image issues.
Handouts about eating disorders, body image, and on-campus resources were available at each event. With the exception of the caricature artists and the slam poet, each event included a short talk given by someone representing the Psychological Counseling Center on campus. This talk provided an overview of NEDAwareness Week, presented signs and symptoms of eating disordered thoughts and behaviors, and described the on-campus services that are available to students experiencing concerns about their body image or eating behaviors.
Interestingly, Tillman et al. found that students surveyed before the events had lower levels of stigma than those who completed the survey after, though the differences were not statistically significant. They did find that students surveyed after the event had higher levels of help-seeking behaviours and better knowledge of campus resources than those surveyed before the events. However, only the latter findings were significant.
WHAT CAN WE CONCLUDE?
Well, not much. While it seems that the campus programming was helpful in increasing students’ factual knowledge of campus resources, it is hard to conclude that it had an impact on students’ help-seeking behaviours or stigma.
Part of the reason is that the researchers didn’t assess change in attitudes before and after the events: Instead, participants were only sampled once. Moreover, the individuals who attended the programming may have had different baselines with regard to stigma and help-seeking attitudes. For example, students attending the EDAW events might have higher levels of self-stigma.
Furthermore, the help-seeking scale used in this study was not specific to eating disorders/body image issues, and it is hard to say whether general help-seeking attitudes apply when it comes to seeking help for eating disorder issues.
As the authors suggest, it is also possible that a one-week/one-time event is not sufficient to reduce stigma, particularly given that (a) none of the events were explicitly aimed to reduce stigma and (b) by the time students reach college, the stigmatizing beliefs may be “ingrained.”
WHAT ELSE DO WE KNOW?
In a similar study, Ridolfi & Vander Wal (2008) assessed the effectiveness of a one-time body image and media literacy session that was a component of EDAW programming, also among college women.
Ridolfi & Vander Wal found that the women who attended the session showed improvements on the body shape questionnaire (at follow-up). However, there were no differences between the women who attended the session and those who did not on: (1) the endorsement of sociocultural influences on appearance, (2) body image quality of life, and (3) appearance investment.
So, that’s kinda weird: It means that the students had fewer body shape concerns but had no changes in the degree to which their body image affected their quality of life, or in how invested they were in appearance. To me this suggests that the positive results were spurious, a fluke. (The authors would disagree.)
The mean scores for the body shape questionnaire decreased by a bit in the group that attended the session but they were still slightly higher than the scores in the control group. (For the nerds: Initial scores in experimental group: 34.22 ± 14.51, control group: 30.09 ± 13.51 . Follow-up scores in experimental group: 31.43 ± 12.77, in the control group: 30.33 ± 13.74.)
BUT HERE’S THE REALLY IMPORTANT PART…
When it comes to program effectiveness, who target audience are really matters. Indeed, Ridolfi & Vander Wal acknowledge this:
Mann et al. (1997) found that when women who had recovered from eating disorders presented a primary prevention session, symptoms of eating disorders actually increased among participants presumably because the presenters may have unintentionally normalized the disorders.
It could be that, or it could be what one of the participants in Ridolfi & Vander Wal’s study experienced:
Of the three participants who reported that the session was a negative experience, one was a woman with a history of an eating disorder who experienced negative memories while listening to the information.
But okay, those were sessions, what about educational messages, like public service announcements or, perhaps, infographics?
In 2009, Sung-Yeon Park and colleagues explored the effects of various PSA messages “comprised of a realistic body image photo and a text emphasizing genetic diversity of body types” on college women’s body satisfaction.
The introduction and discussion in the paper are quite interesting, and the study is more complex than I’m leading you to believe, but I’ll just mention the parts pertinent to the this post.
This was one of the PSA ads they used in the study (the others were similar but were endorsed by “Tropicana” or “Tropicana + NEDA”):
“The theme of genetic diversity was emphasized in the headline of the PSA: Women come in many different shapes. A photo of a university women’s swim team was chosen as the visual element because it illustrated the theme clearly by featuring a number of female bodies varying in shape, size, and height, in spite of same diet and exercise regimen. Right below the photo, a text encouraging self-esteem and self-acceptance was placed. The text read,
‘Although these women go through the same training and diet regimen, they look all different from one another. But, they share one thing—they are great athletes. Whatever you look like outside, it is what’s inside that matters. Be happy about your body. You are one of a kind!’
The source of the message was identified on the bottom of the ad with a brief description:
‘A message sponsored by the NEDA. The NEDA is dedicated to eliminate eating disorders and body dissatisfaction through education and support services.'”
As expected, overall, the ads (there were a few) had a positive effect on body satisfaction, but that’s not the whole story. . .
BUT HOLD ON, WHAT’S THIS?
At the same time, these positive main effects were mostly due to the gains in body satisfaction and the size of the ideal female-body norm by women whose body satisfaction was relatively undamaged to begin with. For women who were already suffering from low body satisfaction, the experimental treatments interacted with the predisposition to the effect that they further deteriorated body satisfaction and the norm of the ideal female body.
This decline in body satisfaction of women with low initial body satisfaction is particularly problematic for many reasons. Foremost, body satisfaction is the ultimate outcome that we want to see improved. Also, the women who were negatively affected are the ones who urgently need an intervention. The harm, no matter how smaller than the benefit, should be taken seriously and ways to amend the problem have to be identified.
SO, WHAT NOW? WHAT NEXT?
To quote Park et al. (2009):
So what do these findings mean to advocates of healthy body image? Most of all, the interactions between pretreatment body satisfaction and the educational messages call for a very careful planning before starting media education campaigns.
To me, the takeaway isn’t to do away with EDAW (or similar endeavours). I didn’t talk in this post about studies that do show positive effects of media literacy, body image, and eating disorder awareness/education programs. There is stuff out there. Importantly, I also didn’t talk about the other positive aspects of EDAW, like bringing people who have struggled with EDs together and, perhaps, enabling some of them to use the opportunity to talk to others and share their experiences (and thus, decrease stigma through personal contact). So, there’s lots of good stuff there I didn’t mention in this post.
My goal was, for the most part, to illustrate that group data sometimes masks really, really important stuff: While overall group effects might be positive, the effects for a crucial subgroup (i.e., those who are predisposed to eating disorders and/or have eating disorder history) might be negative.
This is why it is important to evaluate program and campaign effectiveness, particularly given that the last thing we want to do during EDAW is harm those who are most at risk.
Park, S., McSweeney, J., & Yun, G. (2009). Intervention of Eating Disorder Symptomatology Using Educational Communication Messages. Communication Research, 36 (5), 677-697 DOI: 10.1177/0093650209338910
Ridolfi, D.R., & Vander Wal, J.S. (2008). Eating disorders awareness week: the effectiveness of a one-time body image dissatisfaction prevention session. Eating Disorders, 16 (5), 428-43 PMID: 18821366
Tillman, K.S., Arbaugh, T. Jr., & Balaban, M.S. (2012). Campus programming for National Eating Disorders Awareness Week: An investigation of stigma, help-seeking, and resource knowledge. Eating Behaviors, 13 (3), 281-4 PMID: 22664413