Health Promotion International Advance Access published online on February 8, 2008
Health Promotion International, doi:10.1093/heapro/dan004
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Article |
Prevention programs for body image and eating disorders on University campuses: a review of large, controlled interventions
Health Education and Human Movement, Faculty of Education and Social Work, University of Sydney, Building A35, Sydney 2006, NSW, Australia
* Corresponding author. E-mail: j.o'dea{at}edfac.usyd.edu.au
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SUMMARY |
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Body dissatisfaction, dieting, eating disorders and exercise disorders are prevalent among male and female university students worldwide. Male students are also increasingly adopting health-damaging, body-image-related behaviors such as excessive weight lifting, body building and steroid abuse. Given the severity and difficulty of treating eating disorders, prevention of these problems is a recognized public health goal. Health promotion and health education programs have been conducted in the university setting since the mid 1980s, but few have achieved significant improvements in target health attitudes and behaviors. In this paper, 27 large, randomized and controlled health promotion and health education programs to improve body dissatisfaction, dieting and disordered eating and exercise behaviors of male and female college students are reviewed. In general, health education programs to improve body image and prevent eating disorders in the university setting have been limited by small sample sizes and the exclusion of male students. The majority of studies were conducted among either female undergraduate psychology students or women that were recruited using on-campus advertising. The latter reduces the ability to generalize results to the whole university population, or the general community. In addition, there has been a paucity of longitudinal studies that are methodologically sound, as only 82% (22/27) of interventions included in the review used random assignment of groups, and only 52% (n = 14) included follow-up testing.
Information-based, cognitive behavioral and psycho-educational approaches have been the least effective at improving body image and eating problems among university students. Successful elements for future initiatives are identified as taking a media literacy- and dissonance-based educational approach, incorporating health education activities that build self-esteem, and using computers and the internet as a delivery medium. A newly designed program for Australian university students is described.
Key words: eating disorders; prevention; health promotion; university
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INTRODUCTION |
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Dieting, body dissatisfaction and disordered eating and exercise behaviors are well documented among male (Drummond, 2002
; O'Dea and Abraham, 2002) and female (Crawford and Worsley, 1988; Drenowski et al., 1994; Kenardy et al., 2001; Hill, 2002) university students worldwide.
Between 70 and 94% of female university students express a desire to lose weight and become slimmer (Abraham et al., 1983; Paxton et al., 1991; Vohs et al., 2001), and 80–91% report dieting (Abraham et al., 1983; Striegel-Moore et al., 1990).
Dieting to gain weight has not received equivalent empirical attention, but there is evidence to indicate that this is occurring among young men, with 17% of undergraduate psychology males in the USA (McCreary et al., 2005); and 16 (Yager and O'Dea, 2006) to 28.9% (O'Dea and Abraham, 2001) of male university students in Australia indicating that they diet to gain weight. Male students are also increasingly adopting health-damaging body-image-related behaviors such as excessive weight lifting, body building, steroid abuse (Williamson, 1993; Drummond, 2002; O'Dea and Abraham, 2002).
Among the adult female population in the USA, 0.9% report a lifetime prevalence of anorexia nervosa and 1.5% report bulimia nervosa (Hudson et al., 2007). The prevalence of bulimia nervosa in female American university students is reported to be up to 19% (Halmi et al., 1981; Katzman et al., 1984; Pope et al., 1984; Pyle et al., 1986; Fairburn and Beglin, 1990; Coric and Murstein, 1993). On university campuses, the prevalence of Anorexia Nervosa is between 1 and 4.2% among females (Fairburn and Beglin, 1990; Kurtzman et al., 1989; Pope et al., 1984).
The prevalence of subclinical eating disorders among female university students is far higher, with 61% of female American university students having some sort of subclinical eating problem, including chronic dieting, binge/purging and subclinical bulimia nervosa (Mintz and Betz, 1988). Between 11 and 20% of female American university students score high enough to indicate an eating disorder on the Eating Attitudes Test (Nelson et al., 1999; Prouty et al., 2002; Thome and Espelage, 2004).
Studies of the clinical prevalence of eating disorders report that 5–10% of all individuals who experience eating disorders are male (Carlat and Carmargo, 1991; Lucas et al., 1991). In an Australian study 21% of male university students displayed eating attitudes and behaviors characteristic of eating disorders and disordered eating (O'Dea and Abraham, 2002). Nine percent of male students report that they suffer from disordered eating and 2% meet the criteria to be diagnosed with clinical Bulimia Nervosa (O'Dea and Abraham, 2002).
Given the high prevalence of body dissatisfaction, dieting and eating disorders among university students, many universities have encouraged the implementation of health education and health promotion programs to prevent these body image and eating problems. The aims of the present review are to analyze the prevention programs implemented on university campuses to improve body image and prevent eating disorders and to make recommendations for future preventive initiatives.
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EATING DISORDER PREVENTION IN THE UNIVERSITY SETTING |
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Eating disorders are considered to be serious conditions, with limited success of treatment and high morbidity and co-morbidity with other mental health conditions (Sullivan, 1995
). The prevention of these disorders is well recognized as a necessary public health goal (Paxton, 2000). The university setting also provides an ideal opportunity for the prevention of these problems due to the access to students for screening and diagnosis of problems and the implementation of prevention programs into coursework, in small group programs or at residential colleges and on campus accommodation. Prevention initiatives and interventions have been implemented in the university setting since the mid-1980s, yet they have produced limited success. |
METHODS |
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A thorough literature search was conducted to obtain studies of eating disorder prevention interventions in the university campus setting. Databases including Medline, PreMedline, ProQuest and Wiley Interscience were searched using the terms ‘body image’, ‘body dissatisfaction’, ‘eating disorders’, ‘prevention’, ‘health promotion’, ‘health education’, ‘intervention’, ‘college students’ and ‘university students’. In addition, the reference lists of relevant articles were also scanned for intervention studies, and the issues published in the past 12 months from the following journals were also scanned: Journal of American College Health, Body Image, Eating Disorders, Health Education Research, International Journal of Eating Disorders, Preventive Medicine, Health Promotion International.
Studies were included in the review if they met the following criteria: were from a scientific or academic journal (not unpublished dissertations); implemented a health education or health promotion program aimed at improving body image, reducing body dissatisfaction and/or disordered eating; and included participants who were enrolled at a college or university. Studies were excluded if they did not include a control group.
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RESULTS |
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A summary of all controlled, university campus body image and disordered eating interventions from 1987 to 2007 is presented in Table 1. In general, health education programs to improve body image and prevent eating disorders in the university setting have been limited by small sample sizes (Butters and Cash, 1987
; Rosen et al., 1989; Franko, 1998; Springer et al., 1999; Stice et al., 2000; Stice and Ragan, 2002; Watson and Vaughn, 2006; O'Brien and LeBow, 2007) and the exclusion of male students. The majority of studies were conducted among either female undergraduate psychology students or women that were recruited using on-campus advertising. The latter reduces the ability to generalize results to the whole university population, or the general community. In addition, there has been a paucity of longitudinal studies that are methodologically sound, as only 82% (n = 22) of the 27 interventions included in the review used random assignment of groups, and only 52% (n = 14) included any follow-up testing.
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Almost half of the education programs were conducted among participants who responded to advertisements for female undergraduates with body image concerns to voluntarily participate in studies or discussion groups. This is likely to affect the outcome of the programs, as the women who elected to be involved would have a greater motivation to change (Vansteenkiste et al., 2005
) and some are likely to have been paid for their participation. Health education programs using ‘normal’ cohorts of participants, who were not self-referred or recruited via clinic wait lists, reported that the use of these participants may have been responsible for the disappointing effects of programs, as the participants were not at risk, and may not have found the program content relevant (Nicolino et al., 2001). In addition, authors commented that the participants who do not exhibit disordered eating pathology at pre-test have little scope for improvements in their behaviors, and therefore significant results were not found (O'Brien and LeBow, 2007).
Remarkably, only one eating disorder prevention program in the past 20 years included males. This program (Rabak-Wagener et al., 1998) aimed to improve body image attitudes and behaviors through a psycho-educational, media literacy intervention, and did not report any significant effects among males. The lack of intervention effects among males in this study is likely to be due to the health education program being designed primarily for women, and although it included males, it was not adapted to their specific body image concerns.
The review found that some approaches were not particularly successful, such as didactic, or knowledge-based interventions, psycho-educational and cognitive behavioral interventions. Education programs in the 1980s and 1990s used one-shot, single teaching sessions to provide information about eating disorders, including symptoms and medical complications, in an attempt to prevent the initiation of behaviors and to motivate students with eating disorders to seek treatment (Koszewski et al., 1990). Although some of these studies reported positive results, limitations in methodological design, such as small numbers, lack of follow-up and non-randomized group allocation limit the reliability and generalizability of these results. Those health education programs that reported success included female participants who either responded to advertising inviting women with body image concerns to participate in the study or selected women with elevated body image problems from undergraduate psychology student pools. These factors also limit the widespread application of these health education initiatives to university students.
To develop effective health education and health promotion programs to improve the body dissatisfaction, dieting and disordered eating and exercise behaviors of university students, several effective options for the approach and delivery of interventions have emerged throughout the literature. These include media literacy and dissonance-based approaches with a self-esteem focus and interventions implemented using computers.
Dissonance-based approaches
Cognitive Dissonance Theory (Festinger, 1957) operates on the notion that when there is an inconsistency or dissonance between an individual's health beliefs and behaviors, the resulting psychological discomfort will motivate them to change their attitude or behaviors to reduce this inconsistency (Festinger, 1957; Stice et al., 2000). This approach has been used successfully in influencing health behaviors such as smoking cessation (Killen, 1985) and condom use (Stone et al., 1994). Dissonance-based health education programs have also targeted the internalization of the thin female ideal among young women to reduce body dissatisfaction and disordered eating behaviors (Stice et al., 2000; Stice et al., 2001; Stice et al., 2003; Green et al., 2005).
Dissonance-based approaches have achieved consistent success in reducing thin-ideal internalization, body dissatisfaction, dieting and disordered eating behaviors among female university students as summarized in Table 1vi. Stice and his colleagues (Stice et al., 2000; Stice et al., 2003) in the USA were the first to adapt the use of cognitive dissonance theory to prevent eating disorders, by targeting the reduction of the internalization of the thin ideal. In their dissonance-based health education program, Stice and colleagues (Stice et al., 2000) asked female university students to design an education program that would reduce internalization of the thin ideal in high school girls. This approach was used so that participants would voluntarily assume a counter-attitudinal stance against the thin-ideal themselves (Stice et al., 2000). Green and colleagues (Green et al., 2005) then investigated the impact of the level of dissonance on the success of the education programs, and found that a high level of dissonance (perceived voluntary participation, high level of effort and public expression of their attitudes) achieved greater reductions in eating disorder pathology. Most recently, Roehrig and colleagues identified the counter attitudinal advocacy component (where participants in the education program publicly express their change in beliefs) of the dissonance approach to be successful even in isolation from the other components of a traditional dissonance-based program (Roehrig et al., 2006).
The use of cognitive dissonance is known to be successful in reducing the drive for thinness and internalization of the thin ideal, which is said to improve body dissatisfaction and disordered eating behaviors (Stice et al., 2000; Stice et al., 2003; Green et al., 2005; Roehrig et al., 2006). Importantly, the findings suggest that the dissonance health education approach would be similarly useful for reducing the adherence to the muscular body ideal in males.
Media literacy interventions
There is evidence to suggest that print, broadcast and electronic media both present and reinforce the value of the thin ideal for women and the muscular ideal for men through ideal images and articles about eating disorders (Shulze and Gray, 1990; Heinberg and Thompson, 1995; Agliata and Tantleff-Dunn, 2004). Health education programs based on developing media literacy are based on the assumption that promoting a critical evaluation of the media will reduce its credibility and persuasive influence (Irving and Berel, 2001). This is proposed to reduce cultural body image norms and reduce the internalization of the thin ideal, thereby improving body dissatisfaction, dieting and disordered eating behaviors (Shaw and Waller, 1995).
Media literacy health education programs have been found to improve intended alcohol consumption and acceptance of television violence in young children (Voojis and van der Voort, 1993; Austin and Johnson, 1997). Media literacy interventions that aim to improve body image and eating problems have traditionally been conducted among children (McVey and Davis, 2002; Wade et al., 2003) and adolescents (Levine and Smolak, 2002) and have found positive results.
Media literacy education among university students (as summarized in Table 1v) has typically involved a psycho-educational approach and the viewing of video presentations. These interventions have been very brief, ranging from as little as a one off intervention of 10–45 min (Irving and Berel, 2001; Posovac et al., 2001) to 6 h over a 4-week period (Rabak-Wagener et al., 1998; Watson and Vaughn, 2006). It is reasonable to infer that these brief education programs may be unlikely to effect change compared with a lifetime of exposure to the media. These media literacy education programs have reported some successes in improving body image and thin ideal internalization, but no improvements in target behaviors (Rabak-Wagener et al., 1998; Posovac et al., 2001; Watson and Vaughn, 2006).
It is therefore suggested that a dissonance, rather than a psycho-educational approach to media literacy be used to reduce thin ideal internalization. Interventions that develop dissonance against the thin ideals presented in the media have been successful in achieving behavioral change among female university students (Becker et al., 2005; Stice et al., 2000). This approach to developing media literacy in the university campus population appears to be more successful than the use of psycho-educational or cognitive behavioral approaches, and health promotion programs could be developed to target the development of dissonance against the muscular ideal of men presented in the media to target males.
Additional considerations for future body image education and programs
Incorporation of health promotion activities to build self-esteem: A self-esteem approach toward the prevention of body image and eating problems has been widely used among young children and adolescents. It is based on the self-efficacy component of Bandura's Social Learning Theory and Social Cognitive Theory (Bandura, 1986), which theorize that to change health behavior, individuals must have the required personal skills, perceptions and degree of self-efficacy to do so as well as health-promoting physical environments that provide opportunities for positive health behaviors and social support.
Low self-esteem is known to be a risk factor for body dissatisfaction, dieting, and eating disorders among men and women of all ages (Button et al., 1997; Croll et al., 2002; Stice, 2002) and to the broad spectrum of mental health (Mann et al., 2004). Health education and health promotion programs that have been based on the improvement of self-esteem in adolescents have achieved success in the reduction of body dissatisfaction, dietary restraint and disordered eating (see Table 1) (O'Dea, 1995; O'Dea and Abraham, 2000; McVey et al., 2004). The results of self-esteem health promotion programs and the importance of self-efficacy and self-esteem in behavior change theory suggest that this would be an important addition to an intervention for university students.
Using computer-based delivery methods
Although not a theoretical approach in itself, presenting health promotion information and health education programs through a computer-based medium offers a unique health promotion opportunity. Computer-based interventions have been successfully utilized for behavior change and the treatment of a variety of mental health disorders including depression (Selmi et al., 1990), agoraphobia (Ghosh and Marks, 1987) as well as more general nutrition promotion programs (Oenema et al., 2001) and obesity prevention (Taylor et al., 1991). Online support groups have also become increasingly popular in the treatment and recovery process, and have been used for a variety of health promotion and behavior change initiatives (White and Dorman, 2001).
Internet-based interventions have been described as appealing to university students, and it is known that students are skilled and confident in using these technologies (Robinson et al., 1998). Using the internet for health promotion has the benefit of anonymity, which may enable users to gain access to or discuss sensitive information that they may not be comfortable with in a face-to-face situation (Robinson et al., 1998; Moore et al., 2005). Online health education information is also highly accessible, as resources may be used at any time, and from a variety of locations, and computer access is readily available on the university campus (Robinson et al., 1998; Moore et al., 2005; St Leger, 2006).
The review of recent computer-based health education to promote positive body image and prevent eating disorders is presented in Table 1iv. The majority of studies have revolved around the evaluation of a health promotion body image program called ‘Student Bodies’ (Winzelberg et al., 1998), which was modeled after the ‘Road to Recovery’ program for women with bulimia nervosa (Davis et al., 1989) and cognitive behavioral interventions by Cash (Cash 1991). Student Bodies was originally developed as interactive software that allowed participants to progress through the health education course at their own pace (Winzelberg et al., 1998). It was later altered to be offered as an 8-week education program delivered over the internet (Winzelberg et al., 2000; Celio et al., 2000; Zabinski et al., 2001). Another computer-based body image education program aimed at the university population ‘Food, Mood and Attitude’ [FMA] (Franko et al., 2005) used an interactive CD-ROM based on case studies of university women. This enabled a didactic and psycho-educational intervention that was able to be targeted to both low and high risk participants with equal success (Franko et al., 2005).
Eating disorder prevention programs using a dissonance- and media-literacy-based approach may therefore become more successful if delivered via the internet to the university population. Using the internet would make it possible to screen students for eating disorders using an online questionnaire, and would then allow the appropriate program to be tailored to the individual, or according to gender, thus including males. Such health screening could be linked to campus health referrals hence adding a secondary prevention aspect to the health promotion program. The counter-attitudinal advocacy component of the cognitive dissonance approach may also be particularly effective when implemented using computers, as participants could share their change in attitudes on online discussion boards. In addition to the health promotion benefits of tailored intervention programs, this method could easily be implemented over a larger audience, and is very cost-effective, allowing for a greater range of students to benefit from health promotion initiatives.
Using cognitive dissonance and media literacy education approaches, health promotion targeting the development of self-esteem and presenting some information through computers and the internet have been identified as successful elements of past eating disorder prevention interventions. Given the complementary nature of these preventive elements, we assumed that they may be combined successfully into one intervention aimed at reducing thin ideal internalization, body dissatisfaction and disordered eating behaviors in college women and that the education program could be modified to improve the adherence to the muscular ideal in males. We briefly describe the new health education program below.
A current health education program to improve body image and eating disorders in male and female university students
We designed a longitudinal, controlled, intervention study that uses a combined dissonance- and media-literacy-based education approach and incorporates the promotion of self-esteem using computer-based technologies to improve the body image, body dissatisfaction, dieting and disordered eating behaviors of male and female university students. Participants are male and female students who are training to become physical and health education teachers at three different universities in Australia.
The control group receives the usual health education course content in a didactic, information-based manner, with a purely academic teaching style. In our current program, one group receives similar health education course content as the control group, using a dissonance and self-esteem promotion approach. Low-level dissonance-based education activities (such as voluntary discussion about media gender stereotypes or limitations with the body mass index) aim to reduce students' body dissatisfaction via a reduction in the internalization of the stereotypical thin and muscular ideals. In addition to the theoretical basis for the study, the educational methods employ an interactive, student-centered approach as this type of inclusive and interactive education has been found to increase self-esteem and body image in adolescents (Franko and Orosan-Weine, 1998; O'Dea and Abraham, 2000; O'Dea, 2004).
Our second education program contains higher level dissonance activities and a media literacy education component. Students are involved in small group and online dissonance education discussions about the thin and muscular images presented by the media. An additional focus on the counter-attitudinal advocacy component of the dissonance approach (Roehrig et al., 2006) requires participants to not only reject the thin and muscular ideals, but to voice this in class discussions, online discussion boards and class assignments that involve the discussion of the student's own body image. An online educational component of the program is also used for some class and homework activities, and for the online discussion boards.
We intend to measure the change in male and female students body image after the two different health education programs, and then conduct a 6-month follow-up to determine the effects of prevention over time. No published study to date has tested the efficacy of a combined dissonance education and self-esteem approach, or a self-esteem, dissonance and media literacy education program, nor has this been implemented among both males and females, so we look forward to reporting the results of our study when they become available.
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CONCLUSION |
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Male and female university students are a population at risk of sub-clinical and clinical body dissatisfaction, disordered eating, excessive body building, steroid abuse and eating disorders. The current prevalence of these conditions in university students justifies an urgent health promotion response. Due to the communal setting and academic atmosphere of the university environment, it is possible that health promotion initiatives aimed at protecting students' body image and promoting healthy body image attitudes and behaviors could be effectively implemented as a part of coursework or online activities. However, it is vital that attention is paid to the approach and delivery of the prevention initiatives to ensure that they are suitable and effective for the campus audience. A recent study by Meier et al. (Meier et al., 2007
) explored the contribution of health discussion groups with students to campus health promotion and this approach to community involvement in the planning of campus health promotion programs is recommended. In the current review of all controlled body image and eating disorder education programs over the past 20 years, we have found that information-based, cognitive behavioral therapy and psycho-educational interventions have had limited success and would not be recommended for large-scale university prevention initiatives. Given their previous success among undergraduate populations, we recommend dissonance-, media-literacy- and self-esteem- based educational approaches using some computer-based delivery to improve the body image and related health behaviors of male and female university students. |
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