Running head: THE EFFECTIVENESS OF PRIMARY PREVENTION

Transcription

1 The Effectiveness 1 Running head: THE EFFECTIVENESS OF PRIMARY PREVENTION The Effectiveness of Primary Prevention of Eating Disorders: Brief and Long-Term Programs Anna Jenot and Laura R. Rucker Bowling Green State University

2 The Effectiveness 2 Although eating disorders have been around for centuries much more emphasis has been placed on them in recent decades. Ironically, as average weights have increased, the quest for thinness has become a national obsession (Hales & Hales, 1995, p. 231). The media has been one factor contributing to this by creating an unrealistic picture of the ideal woman who is an unattainable, and for some unhealthy, weight for the vast majority of women. Only the thinnest 5% of women in a normal weight distribution approximate this ideal, which thus excludes 95% of American women (Fall, Katzman, & Wooley, 1994, p. 396). While men also struggle with eating disorders, 90% of those with eating disorders are female (Berg, 1997). With the increase in awareness of eating disorders, treatment has also come into focus. While much research has been done on various treatment approaches, little has been done on prevention programs (Martz & Bazzini, 1999). Eating disorders affect many and have serious mental and physical consequences that may be prevented through intervention programs. Some research ranks eating disorders as the third most common chronic illness among adolescent females in the United States (Neumark-Sztainer, 1996). That statistic, paired with morality rates as high as 10% among those with eating disorders, gives a glimpse into the seriousness of this type of disorder. The focus of this research project will be on two of the major types of eating disorders, anorexia nervosa and bulimia nervosa. Anorexia nervosa is an eating disorder in which people fail to maintain body weights that are normal for their ages and heights and suffer from fears of becoming fat, distorted body images, and amenorrhea (Nolen-Hoeksema, 1998). Individuals with bulimia nervosa engage in bingeing as well as behaviors to prevent weight gain from binges including, self-induced vomiting, excessive exercise, or abuse of purging drugs such as laxatives (Nolen-Hoeksema, 1998).

3 The Effectiveness 3 The general purpose of this study is to examine the effectiveness of eating disorder prevention programs. More specifically, differences between various formats and lengths of time programs run will be examined in terms of effectiveness. The final objective is to determine to what extent these programs produce long term effects. There are several naturally occurring limitations in this study. There is a wide range of ages that eating disorders affect. Many factors are thought to play a role in the development of an eating disorder, however there is no definite, identifiable cause to focus on through prevention programs. Other psychological diagnoses, such as depression, may be related to the occurrence of eating disorders. For example, one study found that, More than half of patients with anorexia nervosa have a history of a major depressive episode that often preceded the onset of the eating disorder indicating that the former is not simply a consequence of the latter (Jimerson, Lesem, Kaye, Hegg, & Brewton, 1990, p. 444). Eating disorders are primarily thought of as a women s problem however men struggle with them as well. It is not known if eating disorders actually occur much more frequently in women or if the small percentage of men reported to have this type of disorder is due to lack of males seeking treatment or being misdiagnosed. Accurate assessment of eating disorders is another limitation. The delimitations of this study include a focus on a small sample during a short period of time. A more comprehensive, large scale study is needed that would examine participants longitudinally and across states and cultures. The differences in primary, secondary, and tertiary intervention programs should also be examined. Primary and secondary forms of intervention programs have been criticized and tertiary programs are not addressed as a part of this research study.

4 The Effectiveness 4 Literature Review In the early 80 s, there was a strong theoretical push in education toward prevention programs of all kinds. Due to the explosion of research and awareness of eating disorders, eating disorder preventative programs became a social trend. There were several different types of programs developed, including primary (prevention of behavior and destructive thought processes), secondary (warning signs and early intervention strategies for those developing an eating disorder), and tertiary (therapy and skills training for those who had an eating disorder) (Nagel & Jones, 1993). Programs also differed in length, including short, brief, or one-shot programs and long term, embedded curriculum programs. Each program was also unique in information covered (nutrition, media influence, self-image), areas stressed (skills and disorder awareness versus personal development and understanding) and the presentation format of the material (school based, hands-on, interactive) (Nagel & Jones, 1993). There are several main issues and concepts that are usually addressed in eating disorder programs. Often, the first goal of the program is to educate students about the dangers and risks involved in eating disorder behavior (Nagel & Jones, 1993). After the students have a better understanding of the disorder itself, they are then taught adaptive and decision making skills that can be used to cope with stress, peer pressure, and self-concept issues. According to Nagel and Jones (1993), food and nutrition information are also important, but should not be the main focus of the program. The researchers believe that self-awareness, development of self-concept and body image, and understanding of the multidimensional role of food (nutritional, psychological, social) in society and the lives of individuals is vital to the long term effectiveness of the program (Nagel & Jones, 1993).

5 The Effectiveness 5 There has also been a recent effort to incorporate cultural sensitivity and awareness into the development of eating disorder prevention programs. According to Nagle and Jones (1993), there must be a focus on sociocultural attitudes and beliefs that may influence or become risk factors in the development of eating disorders. Researchers are also beginning to understand that certain cultures previously believed to be virtually exempt from eating disorders, have a higher incidence and risk rate than expected. A study by Childress, Brewerton, Hodges, and Jarrell (1993) found that African American students displayed less eating disordered concerns and behaviors than Caucasian students, but the levels they did report were surprisingly high in light of the low levels of eating disorders previously believed to exist in the population. Theorists from various schools of thought have different opinions on what preventative eating disorder programs should teach, how the curriculum should be taught, and when such programs should be presented for optimal effectiveness. Some believe that early intervention may actually increase dysfunctional behaviors in otherwise naive children (Johnson & Powers, 1996). According to Rundall and Bruvold (1988) (as cited in Stipek, Sota, & Weishaupt, 1999), scare tactics in prevention programs may actually encourage behaviors by stimulating curiosity and increasing experimentation (p. 437). Yet, research has shown that these behaviors may already be present. According to a study by Childress et al. (1993), the Kids Eating Disorder Survey showed that 40% of the 3,175 participants in grades five through eight reported feeling fat and/or the wish to lose weight. These findings suggest that eating disorder ideation and possibly behavior are present in the preteen population. Since the development of eating disorder prevention programs, there has been a great deal of controversy regarding not only effectiveness, but also the potentially dangerous side effects of the programs. According to Johnson and Powers (1996):

6 The Effectiveness 6 Despite this gratifying interest in the prevention of eating disorders through education, the research thus far has found that broadly-based prevention efforts have not reduced the prevalence of eating disorders. There has been concern that education efforts may have actually increased the likelihood of certain behaviors that may lead to eating disorders by suggesting dangerous strategies to previously naive adolescents (p.1). Johnson and Powers (1996) also suggest that other widespread health education programs may raise concern and, ultimately, disordered eating behavior amongst the targeted population. For instance, the recent rise in males with eating disorders may be due to mass nationwide programs developed to reduce cholesterol, saturated fat intake, and obesity. Individuals exposed to these programs may become overly focused on weight loss or the prevention of weight gain and may use unhealthy weight loss measures (Johnson & Powers, 1996). Is it possible that these prevention/educational programs could be doing more harm than good? From the onset, skeptics have claimed that the educational aspects of the prevention programs (including teen pregnancy and drug abuse programs) were leading to a higher rate of the targeted behaviors. In the case of eating disorder prevention programs, recent research has suggested that such criticisms might be empirically founded. According to Mann, Nolen- Hoeksema, Huang, Burgard, Weright, & Hanson (1997), prevention programs that attempt both primary and secondary prevention have a direct conflict of goals. Primary programs seek to stigmatize behaviors to prevent the development of eating disorders. Secondary programs attempt to destigmatize behaviors in order to empower client and offer hope of eventual recovery. When these two goals are mixed, the end result may be an actual increase in unhealthy eating behaviors, even when destructive thoughts remain unchanged or are actually lessened (Mann et al, 1997).

7 The Effectiveness 7 Yet, in the midst of this controversy there are multiple studies that have found eating disorder programs to be effective in changing behaviors and/or potentially dangerous beliefs. According to Moreno and Thelen (1993), a junior high school educationally-based prevention program was found to be successful in changing subjects knowledge, attitudes, and behavioral intentions regarding some aspect of their eating behavior (p. 109). These positive changes were still evident at a one-month posttest (Moreno & Thelen, 1993). Other programs were found to effectively change or influence thought, but not behaviors. According to Rabak-Wagener, Eickhoff-Shemek, and Kelly-Vance (1998), analyzing and reframing media statements and fashion advertisements caused a significant change in college student behaviors, attitudes, and body image. The goal was to modify students attitudes regarding media credibility and weaken the hold of cultural and social norms that often dictate personal behavior (p. 29). Participants reported a decrease in pressure to diet or exercise in order to meet the media standard of fashion models and they reported an increase in basing such decisions on health issues. However, the posttest results showed that while the changes in attitudes and beliefs remained, behavior changes were lost (Wagener et al., 1998). This may indicate that beliefs and attitudes are easier to change or mold than actual behaviors. Or, perhaps there was a weakness in the behavioral intervention portion of the program. Regardless, this study raises questions of overall program effectiveness and of the relationship between beliefs and behaviors. In concordance with the above research, a study by Martz and Bazzini (1999) found less dieting behavior, less internalization of sociocultural attitudes towards appearance, higher body esteem and increase in help-seeking and referrals to the counseling center in eating disorder prevention program participants. However, these changes were minimal statistically, and were

8 The Effectiveness 8 much stronger in behaviors than beliefs. Martz and Bazzini (1999) hypothesized that the eating disorder beliefs were more difficult to change because they were emotionally centered and therefore based on feelings and values rather than attitudes. Several prevention program studies have indicated an initial change in thoughts and behaviors, only to find that the change was lost in posttests. According to a study by Carter, Stewart, Dunn, and Fairburn (1996), a school based eight week program yielded and increase in knowledge of eating disorders and a decrease in target behaviors. However, at the six-month follow-up these changes had disappeared and there was an actual increase in dietary restraint when compared to the pre-program baseline (Carter et al., 1996). The authors suggest that this means the program did more harm than good. However, perhaps it is not the initial effects of the program that caused the increase, but the lack of long term program effectiveness. The increase in restraint may have occurred in these individuals regardless of, instead of due to, the program itself. It seems a contradiction in terms to blame the program for both lacking long term effectiveness and for causing a long term increase in certain behaviors. It is possible that the best way to utilize eating disorder prevention programs without negatively influencing participants is to target at-risk populations. Profiling and at-risk assessment is underdeveloped at best, especially due to the wide variability among those with eating disorders. Eating disorders can occur regardless of a person s race, socioeconomic status, geographical location, gender, and age. Therefore, screening must be only performed with severe caution in order to avoid excluding anyone who could potentially benefit from the program. According to Shisslak, Crago, Neal, and Swain (1987), risk factors in the development of eating disorders may include age, sex, social class, ethnicity, personality, family dynamics (i.e. enmeshed and overprotective), genetics, sociocultural influences, profession (i.e. dancers,

9 The Effectiveness 9 models, athletes), and pattern of dieting. Some suggested profiles of those with eating disorders include perfectionists and model children who exhibit self-doubt, high conformity, emotional control, inhibited interpersonal relationships, and lack of assertiveness (Nufrio, 1987, p. 1). According to Schwitzer et al. (1998a), using the DSM-IV diagnosis of eating disorders not otherwise specified may help to identify students in need of prevention intervention. The diagnosis is used when there is uncertainty as to the etiology of the disorder (medical, substanceinduced, or primary) or in the case that the client displays some associated behaviors and impaired functioning, but does not meet the full diagnostic criteria. The guidelines of this diagnosis may help to identify those who are currently at risk or vulnerable to disordered eating and thought patterns (Schwitzer et al., 1998a). It is important to note that various researchers and theorists will develop vulnerability or susceptibility profiles according to their personal understanding of, and experience with, treating eating disorders. The question remains, is it better to expose persons who are not characteristically at-risk to prevention programs by being too inclusive, or is the risk of inciting the behaviors with destigmatization a bigger concern? Yet another inherent problem with prevention programs lies in the level of motivation and commitment of the program participants. In primary prevention programs, the goal is to prevent the development of dysfunctional thought patterns or harmful behaviors. Therefore, because the participant often shows no outward signs or symptoms of the disease, the individual feels no urgent need for assistance and has low (or no) motivation for change (Schwitzer, Bergholz, Dore, & Salmi, 1998, p. 202). Individuals may also strive to avoid the stigma attached to any type of intervention, even that which is designed to prevent future

10 The Effectiveness 10 problems (Cullari & Redmon, 1985). This lack of internal motivation may greatly determine the effectiveness of the programs. Ultimately, eating disorder prevention programs are inherently difficult to evaluate (Schwitzer, Bergholz, Dore, & Salmi, 1998). According to Schwitzer, et al. (1998), the perceptions of participants must be considered when assessing the effectiveness of eating disorder prevention programs. Satisfaction surveys can be used to measure how productive and well-matched to their needs the participants perceived the program to be (p. 204). In the case of multi-level programs that combine primary, secondary, and tertiary intervention, it is important to assess the applicability of the program to participants who vary in needs and goals. This can be measured by using pretest/posttest methods involving knowledge, behaviors, and goals for the program. By indicating to what degree their own goals were met, and by identifying new knowledge, skills, and strategies gained in the program, the posttest is invaluable in not only determining effectiveness, but in offering suggestions for changes and improvements that can be made. It is also important to understand the applicability of the program to everyday life and the participants changes in awareness of thoughts, behaviors, and emotions, and relationships to others. According to Cullari and Redmon (1985), assessments of prevention programs are inherently skewed because certain effects are overlooked by current assessment strategies. A program may effectively prevent further deterioration in the experimental group, but how can this be measured statistically? Also, when considering posttest effectiveness, how can researchers claim that the program lessened the occurrence of eating disorders without knowing that disorders would have occurred without intervention (Cullari & Redmon, 1985)?

11 The Effectiveness 11 Unfortunately, much program assessment is done in pilot programs with small, often unrepresentative groups. Minimal funding and other lack of resources may force researchers to depend on reviewed rather than tested interventions and their own clinical judgement. In the case of eating disorder prevention programs, this method may actually cause more harm than good (Schwitzer et al., 1998b). Therefore, making a generalized statement about the effectiveness of eating disorder prevention programs as a whole, is difficult. As is evident, research on the effectiveness of eating disorder prevention programs is conflicting at best. Even if certain specific programs are beneficial, there is still an alarming trend of ineffective and potentially mal-effective programs. Therefore, the purpose of this study is to determine the effectiveness of a brief and a long-term, embedded curriculum program within a diverse, middle school sample. Methodology The proposed research study will sample from a large, ethnically diverse, suburban middle/junior high school in the Midwest. Informed consent will be obtained through cover letters directed to the students and cover letter/permission slips directed to the parents. If consent is not obtained from both parties, students will not participate. The researchers will also obtain permission for, and approval of, the study from the school board, superintendent, principal, and teachers in order to ensure a cooperative learning and research environment. Participants will include fifth grade health class students ages 10 through 11 and the sample will be obtained through a clustering process. Should the proposed study yield reliable results, the format will be repeated with other grades. The ideal objective is to have a sample of 30 each for a control group, experimental group 1 (brief program), and experimental group 2

12 The Effectiveness 12 (long term embedded curriculum program). The sample will consist of 45 males and 45 females and will have Latino/a, African American, Asian-Pacific Islander, and Caucasian representatives. The Kids' Eating Disorders Survey (Childress et al., 1993) will be used to pre- and posttest (six month follow-up) the students. This survey had a norm group of 3,175 students, 1,610 females and 1,565 males, ranging from grade 5 to 8. Frequencies of weight control behaviors were found to be statistically significant at the.05 level. An open-ended satisfaction survey will be distributed to the students at the termination of the program and will be used to assess the applicability of the program, knowledge gained, and goals met. The data will be collected in survey form during a standard health class and the teacher will distribute all surveys. The data will be assessed for sample representativeness using frequencies. An analysis of variance will be used to compare the groups (control, short-term, and long-term) according to changes in targeted beliefs/attitudes and behaviors. A six-month posttest ANOVA will be used to determine the long-term effects of the experiment on all groups. Data will be considered statistically significant at a.05 alpha level.

13 The Effectiveness 13 References Berg, F. M. (1997). Afraid to eat: Children and teens in weight crisis. Hettinger, ND: Healthy Weight Journal. Carter, J. C., Stewart, D. A., Dunn, V. J., & Fairburn, C. G. (1996). Primary prevention of eating disorders: Might it do more harm than good? Childress, A., Brewerton, T., Hodges, E., & Jarrell, M. (1993). The Kids Eating Disorder Survey (KEDS): A study of middle school students. Journal of the American Academy of Child and Adolescent Psychiatry, 32 (4), Cullari, S. & Redmon, W. K. (1985). A primary prevention program to reduce bulimia and anorexia nervosa. Fall, P., Katzman, M. A., & Wooley, S. C. (Eds.). (1994). Feminist perspective on eating disorders. New York: The Guilford Press. Hales, D. & Hales, R. E. (1995). Caring for the mind: The comprehensive guide to mental health. New York: Bantam Books. Jimerson, D. C., Lesem, M. D., Kaye, W. H., Hegg, A. P., & Brewerton, T. D. (1990). Eating disorders and depression: Is there a serotonin connection? Biological Psychiatry, 28, Johnson, C. & Powers, P. S. (1996). Elite athletes and eating disorders: Prevention efforts in an at risk group. Newsletter of the American Anorexia-Bulimia Association Inc Mann, T., Nolen-Hoeksema, S., Burgard, D., Wright, A., & Hanson, K. (1997). Are two interventions worse than none? Joint primary and secondary prevention of eating disorders in college females. Health Psychology, 16 (3),

14 The Effectiveness 14 Martz, D. M. & Bazzini, D. G. (1999). Eating disorders prevention programming may be failing: Evaluation of 2 one-shot programs. Journal of College Student Development, 40 (1), Moreno, A. B. & Thelen, M. H. (1993). A preliminary prevention program for eating disorders in a junior high school population. Journal of Youth and Adolescence, 22 (2), Nagel, K. L. & Jones, K. H. (1993). Eating disorders: Prevention through education. Journal of Home Economics, Neunmark-Sztainer, D. (1996). School-based programs for preventing eating disturbances. Journal of School Health, 66 (2), Nolen-Hoeksema, S. (1998). Abnormal psychology. Dubuque, IA: McGraw-Hill. Nufrio, R. M. (1987). Anorexia nervosa: An overview for the school counselor Omizo, S. A. & Omizo, M. M. (1992). Eating disorders: The school counselor s role. The School Counselor, 39, Rabak-Wagener, J., Eickhoff-Shemek, J., & Kelly-Vance, L. (1998). The effect of media analysis on attitudes and behaviors regarding body image among college students. Journal of American College Health, 47 (1), 29. Schwitzer, A. M., Bergholz, K., Dore, T., & Salimi, L. (1998). Eating disorders among college women- Prevention, education, and treatment responses. Journal of American Health, 46 (5) Shisslak, C. M., Crago, M., Neal, M. E., & Swain, B. (1987). Primary prevention of eating disorders. Journal of Consulting and Clinical Psychology, 55 (5),

15 The Effectiveness 15 Stipek, D., de la Sota, A., & Weishaupt, L. (1999). Life lessons: An embedded classroom approach to preventing high-risk behaviors among preadolescents. The Elementary School Journal, 99 (5),