Eating Disorders, 18:267285, 2010

Copyright Taylor & Francis Group, LLC

ISSN: 1064-0266 print/1532-530X online
DOI: 10.1080/10640266.2010.490115

Eating Disorders Mental Health Literacy in

Low Risk, High Risk and Symptomatic Women:
Implications for Health Promotion Programs
JONATHAN M. MOND
School of Biomedical and Health Sciences, University of Western Sydney, Campbelltown,
New South Wales, Australia

PHILLIPA J. HAY
School of Medicine, University of Western Sydney, Campbelltown, New South Wales; and
School of Medicine, James Cook University, Townsville, Queensland, Australia

SUSAN J. PAXTON
School of Psychological Science, LaTrobe University, Bundoora, Victoria, Australia

BRYAN RODGERS
Australian Demographic and Social Research Unit, Australia National University, Canberra,
Australian Capital Territory, Australia

ANITA DARBY
South Eastern Sydney Illawarra Area Health Service, Wollongong,
New South Wales, Australia

JODI NILLSON
Department of Psychology, University of Tasmania, Hobart, Tasmania, Australia

FRANCES QUIRK
School of Psychology, James Cook University, Townsville, Queensland, Australia

CATHY OWEN
Rural Clinical School, Medical School, Australian National University,
Canberra, Australian Capital Territory, Australia

The research was funded by the Australian Rotary Health Research Fund. Dr. Mond
is funded by a National Health and Medical Research Council Sidney Sax (Public Health)
Fellowship.
Address correspondence to Jonathan M. Mond, Ph.D., M.P.H., School of Biomedical and
Health Sciences, University of Western Sydney, Campbelltown Campus, Locked Bag 1797,
Penrith South DC, NSW 1797, Australia. E-mail: j.mond@uws.edu.au

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Attitudes and beliefs concerning the nature and treatment of

bulimia nervosa (BN) were compared among young adult women
at low risk of an eating disorder ( n = 332), at high risk ( n = 83),
or already showing symptoms ( n = 94). Participants completed a
self-report questionnaire that included a measure of eating disorder symptoms. A vignette of a fictional person suffering from
BN was presented, followed by a series of questions addressing
the nature and treatment of the problem described. High-risk and
symptomatic participants were more likely than low-risk participants to report that they would not approach anyone for advice
or help, were they to have BN or a similar problem, because they
would not want anyone to know. Symptomatic participants were
more likely to believe that someone with BN would be discriminated
against, more likely to consider bulimic behaviors to be acceptable, and more likely to view BN as being common among women
in the community, than low-risk participants, participants in the
high-risk group being intermediate on each of these questions. The
findings suggest that the attitudes and beliefs of individuals with
eating disorder symptoms differ systematically from those of individuals at high risk, but who do not yet have symptoms, and from
those at low risk. They also indicate specific attitudes and beliefs
that may need to be addressed in prevention and early intervention
programs. The potential benefits of assessing individuals attitudes and beliefs concerning the nature and treatment of eatingdisordered behaviour and tailoring program content accordingly
may be worthy of investigation.

A fundamental premise of psycho-educational approaches to mental health

promotion, and health promotion more generally, is that the likelihood of
success of any given intervention will be increased if the program content
is tailored to the knowledge and beliefs of the individuals receiving the
intervention (Kreuter, Strecher, & Glassman, 1999). In developing program
content for individuals with symptoms, for example, it would make sense
to address knowledge and beliefs likely to impede early and appropriate
treatment-seeking, such as poor recognition of symptoms, poor knowledge
of evidence-based treatment and perceived stigma associated with disclosure
of problem behaviors (Hay, Mond, Darby, Rodgers & Owen, 2007). For
individuals at little or no risk, by contrast, it may be more helpful to improve
knowledge of how best to intervene with others who may have symptoms
or be at risk (Hart, Jorm, Paxton, Kelly & Kitchener, 2009).
A useful framework for organizing knowledge and beliefs relating to
mental health problems is that of mental health literacy, namely, knowledge and beliefs about mental disorders that may aid in their recognition,

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269

management and treatment (Jorm et al., 1997a). Jorm and colleagues,

and others, have argued that poor mental health literacy is a major factor
in the individual, social and economic burden of mental health problems (Andrews, Sanderson, Slade, & Issakidis, 2000; Jorm, Angermeyer &
Katschnig, 2000). Poor mental health literacy includes not only poor awareness and understanding of the nature and treatment of mental health
problems, but also attitudes and beliefs likely to be conducive to stigmatisation of and discrimination against sufferers (Crisp, Gelder, Rix, Meltzer, &
Rowlands, 2000; Mond, Robertson-Smith, & Vitere, 2006).
Research conducted by the authors, relating to eating disorders mental
health literacy, suggests that the attitudes and beliefs of individuals with eating disorder symptoms do indeed differ from those of healthy women on a
range of issues concerning the nature and treatment of bulimia nervosa (BN)
(Mond, Hay, Rodgers, Owen & Beumont, 2004a, b, c). Thus, we found that
women with eating disorder symptoms were more likely to consider bulimic
behaviors to be acceptable, more likely to over-estimate the prevalence of
BN among women in the general population, less likely to believe that a
psychiatrist would be helpful in the treatment of BN, more likely to consider
childhood sexual abuse as a cause of BN, and more likely to consider low
self-esteem to be the primary cause of BN, than women who did not have
symptoms.
However, methodological limitations of this earlier research precluded
any firm conclusions. For one thing, comparison of subgroups with different risk/symptom profiles was not an a priori aim of the research. Moreover,
only two subgroups, namely, those with symptoms and those with no symptoms, were considered and the number of participants with symptoms was
too small to permit confidence in the between-group differences observed.
The findings did suggest, however, that a more systematic analysis would be
of interest. If it could be shown that the attitudes and beliefs of individuals
with different risk/symptom profiles differ in characteristic ways, then this
information might be used to inform the design of health promotion programs by indicating the specific attitudes and beliefs that might be addressed
in different sub-groups of individuals.
With these considerations in mind, the goal of the present study was
to compare attitudes and beliefs concerning the nature and treatment of BN
between young adult women: (a) at low risk of eating disorder symptoms;
(b) at high risk; and (c) already showing symptoms. BN was chosenthat
is, in preference to anorexia nervosabecause BN and variants of BN not
meeting formal diagnostic criteria are common, disabling and associated
with very low uptake of mental health care (Mond et al., 2006; Mond, Hay,
Rodgers, & Owen, 2007a). Young adult women were chosen because early
adulthood is the peak age of onset for bulimic behaviors and because these
behaviors are more common in women than in men (Hay, Mond, Darby, &
Buttner, 2008; Mond & Hay, 2007; Striegel-Moore et al., 2009).

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The survey was designed to address attitudes and beliefs on a range

of topics considered to have implications for prevention and early intervention programs, including: problem recognition; beliefs about the helpfulness
of various treatments and treatment providers; beliefs about prognosis;
beliefs about etiological factors; beliefs about the likelihood of individuals
with symptoms experiencing discrimination; and perceptions of prevalence
and severity. We hypothesized that the attitudes and beliefs of participants in the different risk/symptom subgroups would differ from each
other in responses to at least some of the questions addressing these
topics.

METHOD
Study Design and Participants
The data were collected as the baseline assessment of a longitudinal study of
outcome among women with eating disorder symptoms. Participants were
(primarily) young adult women from four tertiary education campuses in two
states of Australia (Queensland and Victoria). Recruitment strategies varied
and included approach via central University email/web mail, printed advertisements in student bulletins and halls of residence and direct approach
to students in University common areas. For individuals approached via
email, participants were given the option of completing an on-line questionnaire. For other participants, questionnaires were provided in hard copy
with reply-paid envelopes. The questionnaire included, in addition to the
mental health literacy survey, measures of eating disorder psychopathology
and quality of life (cf. Mond, Rodgers et al., 2004).
The total sample comprised 756 women with a mean (SD) age of
27.2 (10.7) years (median = 22.0, IQR = 13). The inclusion of some
participants aged 45 years or higher (n = 79, 10.5%) reflects the enrolment
of mature-age students and members of staff at some campuses. Reflecting
the demographic profile of the regions sampled, most participants were
born in Australia (80.2%). Given the methods of recruitment employed,
it was not possible to determine response rates and no information was
available concerning the characteristics of non-respondents. However,
comparison of participants scores on the eating disorder symptom measure
with those of a normative sample suggested that levels of eating disorder
psychopathology in the present study sample were somewhat higher than
those observed in general population samples, as would be expected in
a student sample (Luce, Crowther, & Pole, 2008). Participants quality of
life was comparable to that of a general population sample of young adult
women (Mond, Rodgers et al., 2004).

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Study Measures
MENTAL HEALTH LITERACY SURVEY
The mental health literacy survey was modelled on the work of Jorm and colleagues (Jorm et al., 1997a) with appropriate modifications for the study of
an eating problem and for administration in a self-report format (Mond et al.,
2004 a,b,c). A vignette describing a (fictional) 19-year-old female (Naomi)
suffering from BN was first presented (see Appendix A). Care was taken to
ensure that the core features of the disorder were present while avoiding
the use of medical terminology.
Following presentation of the vignette, participants were first asked:
What would you say is Naomis main problem? They were required to
choose one answer only from a list of options provided. Options, listed in a
pre-determined, random order, were: bulimia nervosa; anorexia nervosa;
an eating disorder, but not anorexia or bulimia; yo-yo dieting; poor diet;
low self-esteem/lack of self-confidence; depression; an anxiety disorder
or problem; stress; a nervous breakdown; a mental health problem;
and no real problem, just a phase.
Participants were required to indicate which of a number of possible interventions within each of three categoriespeople (15 options),
treatments/activities (12 options), and medicines/pills (4 options)they
believed would be most helpful for Naomi (see Table 3 for the complete list
of options), as well as the person that they would first approach for advice
or help were they to have a problem such as the one described. Participants
were also asked about Naomis likely prognosis were she to receive the
treatment considered most appropriate, with (6) response options ranging
from full recovery with no further problems to get worse.
Perceived severity was assessed with the question: How distressing
do you think it would be to have Naomis problem?, whereas perceived
acceptability was assessed with the question: Have you ever thought that
it might not be too bad to be like Naomi, given that she has been able to
lose a lot of weight? Five-point Likert-type scales were employed for these
questions. In addition, participants were asked whether or not they believed
Naomi would be likely to experience discrimination, were others to become
aware of her problem.
Perceived prevalence was assessed with the question: How many
women in the community do you think might have Naomis problem at any
given point in time? response options ranging from few women, less than
10% to most women, 90% or more. Beliefs about etiological factors were
addressed by asking participants to indicate which of a number of factors
was most likely to be a cause of Naomis problem developing in anyone.
The options (n = 18) included a broad range of dispositional (e.g., having a
nervous disposition, being a perfectionist, having low self-esteem) and
environmental (e.g., childhood trauma, being overweight as a child or

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adolescent, portrayal of the ideal body shape in the media) factors (cf.
Mond et al., 2004c).
The survey ended with a question addressing participants personal
experience of an eating disorder or problem, namely: Do you think you
might currently have a problem such as the one described? Do you think
you have ever had a problem such as the one described? and Has anyone in your family or circle of friends ever had a problem such as the one
described?

EATING DISORDER EXAMINATION QUESTIONNAIRE (EDE-Q)

The EDE-Q (Fairburn & Beglin, 1994) is a 36-item, self-report version of
the Eating Disorder Examination interview (Fairburn & Cooper, 1993). The
EDE-Q focuses on the past 28 days and is scored using a 7-point, forcedchoice, rating scheme. Scores on each item range from 0 to 6, with
higher scores indicating higher symptom levels. Scores on four subscales
(Restraint, Eating Concern, Weight Concern and Shape Concern) and a
global score may be derived from 22 items addressing attitudinal aspects
of ED psychopathology (Mond, Hay, Rodgers, & Owen, 2006a). A high
level of agreement between EDE-Q and EDE subscale and global scores
has been demonstrated in various study populations (cf. Fairburn & Beglin,
1994; Mond, Hay, Rodgers, Owen, & Beumont, 2004d). Cronbach alphas
in the present study ranged from 0.81 (Restraint subscale) to 0.95 (global
score).
Remaining items of the EDE-Q assess the occurrence and frequency
of eating disorder behaviors. Agreement between self-report and interview
assessment of eating disorder behaviors has been found to be lower and
more variable than that of the items assessing attitudinal features (Fairburn &
Beglin, 1994; Mond et al., 2004d). Interview assessment of binge eating is
generally considered to be superior to self-report assessment, whereas the
superiority of interview assessment of self-induced vomiting and laxative
misuse is less clear (Mond, Hay, Rodgers, & Owen, 2007b).

MEDICAL OUTCOMES STUDY (12-ITEM) SHORT FORM (SF-12)

Quality of life was assessed with the Medical Outcomes Study Short-Form
(12-item) disability scale (SF-12; Ware, Kosinski, & Keller, 1996), a self-report,
generic measure of health-related quality of life. Items are summarized
into two weighted scales (Physical Component Summary scale, PCS; Mental
Component Summary scale, MCS), designed to assess impairment in role
functioning associated with physical and mental health problems. Each scale
is scored to have a mean of 50 and standard deviation of 10 (in the US
population), with lower scores indicating higher levels of impairment. The

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273

SF-12 has good psychometric properties (Ware et al., 1996) and its validity
in the Australia population has been demonstrated (Sanderson & Andrews,
2002). A score of 30 or less on the MCS indicates severe impairment in
mental health, whereas a score between 31 and 40 indicates moderate
impairment (Sanderson & Andrews, 2002). Cronbachs alpha in the present
study was 0.82.

Derivation of Study Subgroups

In the absence of any agreed-upon operational definitions of risk status or
eating disorder case, we relied on our experience with general population
surveys of women to inform the derivation of study subgroups (Mond et al.,
2004d; 2006a; Mond, Hay, Rodgers, & Owen, 2007c). Specifically, participants were classified into one of three mutually exclusive categories based
on their scores on the two EDE-Q items that assess the undue influence of
weight or shape on self-evaluation and the items assessing eating disorder
behaviors. The undue influence of weight or shape on self-evaluation is a
potent risk factor for the development and maintenance of eating disorder
psychopathology, while also being a diagnostic feature of anorexia nervosa
and BN (APA, 1994; Stice, 2002).
Participants were deemed to be low risk if they had scores of 2 or less
on both the Importance of Weight and Importance of Shape items (indicating that weight or shape had little or no influence on self-evaluation) and
did not (currently) have any regular eating disorder behaviors. Participants
were classified as high risk if they had scores of 5 or 6 on either or both
Importance of Weight and Importance of Shape items (indicating a marked
influence of weight or shape on self-evaluation), but did not have any regular eating disorder behaviors. Participants who had scores of 5 or 6 on either
or both Importance of Weight and Importance of Shape items in conjunction with one or more regular eating disorder behaviors were classified as
symptomatic.
In order to effect a clearer separation between groups, data for 247
women who did not meet criteria for any of these groups were excluded.
The number of participants in the low-risk, high-risk and symptomatic
groups was 332 (43.9%), 83 (11.0%), and 94 (12.4%), respectively. As can
be seen in Table 1, participants in the symptomatic group had very high
levels of eating disorder psychopathology and impairment in mental health
as measured by the SF-12 MCS.

Statistical Analysis
Item non-response varied from 0.6% for the question addressing Naomis
main problem to 6.9% for the question addressing medicines/pills (mean =

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J. M. Mond et al.

TABLE 1 Mean Age, Body Mass Index (BMI) (Kg/M2 ) and Scores on Measures of Eating
Disorder Psychopathology (EDE-Q Subscales) and Health-Related Quality of Life (SF-12 PCS,
MCS) Among Young Adult Women Classified as Low-Risk, High-Risk or Symptomatic

Age
BMI
EDE-Q subscalesi
Restraint
Eating concern
Weight concern
Shape concern
Global score
SF-12 PCSii
SF-12 MCSiii

Low risk
(n = 332)

High risk
(n = 83)

Symptomatic
(n = 94)

Mean (SD)

Mean (SD)

Mean (SD)

Post-hoc

27.96 (11.62)
23.02 (4.72)

28.21 (9.74)
25.39 (6.37)

25.04 (8.67)
25.72 (6.89)

2.88
12.05

.06
<.001

NSD
1 < 2, 3

0.84
0.30
0.95
1.27
0.84
52.53
48.43

2.07
1.45
3.37
3.77
2.66
52.08
40.02

3.55
3.17
4.52
4.76
4.00
50.96
34.56

186.49
391.95
502.79
615.70
560.42
1.63
77.72

<.001
<.001
<.001
<.001
<.001
.20
<.001

1<2<3
1<2<3
1<2<3
1<2<3
1<2<3
NSD
1<2<3

(1.02)
(0.44)
(0.86)
(0.96)
(0.67)
(6.69)
(9.41)

(1.44)
(1.16)
(1.17)
(1.29)
(1.02)
(8.07)
(12.10)

(1.62)
(1.53)
(1.03)
(1.03)
(1.12)
(9.12)
(10.69)

i. Eating Disorder Examination Questionnaire subscale and global scores.

ii. Medical Outcomes Study (12-item) Short Form Physical Component Summary scale.
iii. Medical Outcomes Study (12-item) Short Form Mental Component Summary scale.

3.1%). Data are presented as the percentage (%) of participants who

endorsed each possible response for each question. Associations between
group (low-risk, high-risk and symptomatic) and responses to specific questions were examined by means of Chi-square tests. Where appropriate,
standardized residual (SR) values were considered in order to clarify the
source of differences that were significant or that approached significance at
the .05 level.

RESULTS
Table 2 shows responses to the question concerning Naomis main problem. Symptomatic participants were more likely to believe that the main
problem was depression (SR = +3.3), and less likely to believe that the
main problem was low self-esteem (SR = 2.0), than low- and high-risk
participants ( 2 = 32.64, df = 22, p = .07).
Responses to the questions concerning the people, treatments or activities, and medicines/pills considered most likely to be helpful for Naomi
are summarized in Table 3. There were no differences between groups in
responses to any of these questions (all p > .10).
Concerning the person participants would approach first were they
to have a problem such as the one described, the modal response in
the low-risk group was a close friend (27.3%), followed by general
practitioner (23.0%), whereas the modal response among high-risk participants was no-one/I wouldnt want anyone to know (19.5%), followed

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TABLE 2 Perceptions of Naomis Main Problem by Risk/Symptom Profile: Proportion (%)

of Participants in Each Group Endorsing Each Option

Depression
AN
BN
Stress
Anxiety disorder
Low self-esteem
Poor diet
Yo-yo dieting
An eating disorder but not
anorexia or bulimia
Mental health problem
No real problem, just a phase
Other

Low risk %

High risk %

Symptomatic %

1.8
3.9
21.1
0.3
4.2
35.6
1.2
2.4
11.8

2.5
1.2
19.8
0.0
3.7
37.0
1.2
3.7
13.6

9.6
4.3
24.5
1.1
2.1
21.3
0.0
7.4
9.6

14.8
0.6
2.1

14.8
0.0
2.5

16.0
2.1
2.1

by close friend (15.9%). No-one/I wouldnt want anyone to know was

also the modal response among symptomatic participants (24.2%), followed
by close friend (22.0%) ( 2 = 60.72, df = 26, p < .001). High-risk
(SR = +2.4) and symptomatic (SR = +3.8) participants were more likely to
give the response No-one/I wouldnt want anyone to know than low-risk
participants (SR = 3.2).
In all three groups, the modal response to the question addressing
Naomis likely prognosis, were she to receive the treatment considered
appropriate, was full recovery, but problems will probably re-occur
(43.5%47.5%), whereas fewer participants believed that there would be
full recovery with no further problems (18.5%28.6%). There was a
tendency for high-risk and symptomatic participants to be less likely to
endorse the full recovery with no further problems option than low-risk
participants, and vice-versa ( 2 = 15.04, df = 8, p = .06).
For all three groups, the modal response to the question addressing
the most likely cause of the problem described was low self-esteem (lowrisk: 37.3%; high-risk: 34.2%; symptomatic: 30.9%). Also in all three groups,
the next most frequently endorsed option was portrayal of the ideal body
shape in the popular media (low-risk: 13.7%; high-risk: 18.4%; probable
cases: 19.1%) ( 2 = 37.43, df = 32, p = .23).
Responses to the questions addressing perceived severity and acceptability are summarized in Table 4. Symptomatic participants were more likely
to report being extremely sympathetic (SR = +3.1), and less likely to be a
little sympathetic (SR = 2.1), than participants in the low- and high-risk
groups ( 2 = 22.92, df = 8, p < .01). Symptomatic participants were also
more likely to have occasionally, often or always thought that it might not
be too bad to have Naomis problem than high-risk participants, who were,

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TABLE 3 Perceived Helpfulness of Interventions for Naomis Problem by Risk/Symptom

Profile: Proportion (%) of Participants in Each Group Who Reported That Specific
Interventions Within Each of Three CategoriesTreatments/Activities, People, and
Medicines/PillsWould Be Most Likely To Be Helpful

Treatments/activities that might be helpful

Just talking about the problem
Psychotherapy focusing on past causes
Cognitive behavior therapy
Psychotherapy focusing on relationships
General psychotherapy
Alternative therapy
Relaxation therapy
Assertiveness or social skills training
Admission to public hospital psych ward
Private psych ward
Self-help treatment manual
Getting fitter/increasing exercise
Getting out more/finding new hobbies
Getting info on problem and services
Trying to deal with problem on own
Other
People who might be helpful
General practitioner (family doctor)
Counsellor
Social worker
Psychiatrist
Psychologist
Family member
Close friend
Dietician or nutritionist
Naturopath or alternate therapist
Community health worker/team
Self help support group
Commercial wt loss program
Other
Medicines/pills that might be helpful
Vitamins and minerals
Herbal medicines
Anti-depressant
Medication to help relax
None/unsure

Low risk

High risk

Symptomatic

21.0
3.2
19.4
8.7
4.9
1.9
5.2
0.6
0.0
0.6
0.6
0.0
10.7
18.1
0.3
4.5

15.6
5.2
26.0
6.5
1.3
1.3
7.8
2.6
0.0
3.9
0.0
1.3
9.1
16.9
0.0
2.6

17.4
4.3
17.4
8.7
2.2
2.2
4.3
1.1
1.1
0.0
1.1
1.1
9.8
23.9
1.1
4.4

16.3
12.5
1.9
4.5
16.3
6.1
10.9
19.2
1.9
1.6
4.5
0.3
3.8

7.8
10.4
0.0
6.5
19.5
2.6
7.8
23.4
1.3
0.0
10.4
2.6
7.8

16.7
15.6
2.2
5.6
18.9
4.4
7.8
21.1
1.1
1.1
2.2
1.1
2.2

64.2
9.4
13.5
0.3
13.6

53.9
18.4
15.8
0.0
11.9

56.8
9.1
22.7
1.1
10.2

in turn, more likely to give these responses than low-risk participants ( 2 =

179.20, df = 8, p < .001).
A similar gradientfrom low-risk to high-risk to symptomaticwas
apparent in responses to the questions addressing the perceived likelihood
of Naomi being discriminated against (low-risk : 40.4%; high-risk: 48.1%;
symptomatic: 60.6%; 2 = 12.27, df = 2, p < .01) and the perceived prevalence of the problem described (low-risk: modal response =

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TABLE 4 Perceptions of the Severity and Acceptability of Naomis Problem by Risk/Symptom

Profile: Proportion (%) of Participants in Each Group Endorsing Specific Responses to Each
Question

How distressing do you think it would

be to have Naomis problem?
Not at all distressing
A little distressing
Moderately distressing
Very distressing
Extremely distressing
Have you ever thought it might not
be too bad to be like Naomi, given
that she has been able to lose weight?
Never
Rarely
Occasionally
Often
Always

Low risk
%

High risk
%

Symptomatic
%

0.3
7.0
10.4
49.5
32.7

0.0
2.5
18.5
43.2
35.8

2.1
5.3
11.7
41.5
39.4

67.7
22.9
7.3
1.5
0.6

32.9
24.4
22.0
12.2
8.5

13.8
14.9
28.7
28.7
13.8

10%30%; high-risk: 30%50%; symptomatic: 50%70%; 2 = 40.00,

df = 12, p < .001).
As would be expected, the proportion of participants who believed
that they might currently have an eating problem differed markedly
between groups, although still only half (52.7%) of participants classified
as symptomatic believed that they might currently have a problem such as
the one described (low-risk: 2.1%, high-risk: 16.9%) ( 2 = 155.99, df = 2,
p < .001).

DISCUSSION
Summary of Main Findings
We compared attitudes and beliefs concerning the nature and treatment
of BN in three groups of women: those at low-risk for an eating disorder, those at high-risk, and those already showing symptoms. The survey
addressed a range of topics considered to have implications for health promotion efforts, including problem recognition, beliefs about the helpfulness
of treatments and treatment providers, beliefs about prognosis, beliefs about
etiological factors, perceptions of prevalence and severity and beliefs about
the likelihood of discrimination.
In all three groups, cognitive behavior therapy and self-help interventions, such as just talking about the problem and getting information about
the problem and available services, were the treatments considered most
likely to be helpful, whereas primary care practitioners, namely, general

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J. M. Mond et al.

practitioners and dieticians or nutritionists, counsellors and psychologists

were the treatment providers considered most likely to be helpful. Taking
vitamins and minerals was also highly regarded, whereas few participants
believed that psychotropic medication would be helpful. Also in all three
groups, most participants viewed the problem described as being very or
extremely distressing and most considered low self-esteem to be the most
important etiological factor.
Differences between groups were, however, observed on other items.
High-risk and symptomatic participants were more likely than low-risk participants to report that they would not approach anyone for advice or help,
were they to have a problem such as the one described, because they would
not want anyone to know. High-risk and symptomatic participants also
tended to be more negative about the prognosis of someone treated for BN.
Symptomatic participants were far more likely to consider bulimic behaviors
to be acceptable, and common among women in the community, than participants in the low-risk group, with participants in the high-risk group being
intermediate on these questions. Finally, participants with symptoms were
more likely than low- and high-risk participants to believe that someone
with BN would be likely to be discriminated against, were others to become
aware of the problem.

Study Limitations
Several limitations of the present study should be considered when interpreting these findings. First, in the absence of any agreed-upon operational
definitions of terms such as low-risk and high-risk, we developed definitions informed by our previous research. Different findings might have
been observed had different definitions been used for one or more groups.
Second, this was a study of attitudes and beliefs about BN. Although many
aspects of eating disorders mental health literacy appear to cut across diagnostic boundaries (Mond & Hay, 2008), responses to some questions would
likely have differed had a vignette of anorexia nervosa or binge eating
disorder been presented. Third, recruitment of participants form a student
population may limit generalizability, although it may be noted that findings
in the low-risk group were similar to those of previous research in a general
population sample of women (Mond et al., 2004a,b,c). Fourth, only females
were included. Although this made it possible to recruit adequate samples
of both high-risk and symptomatic participants, it would be preferable to
include males in future research. In our view, a broadening of universal prevention programs to include the attitudes, beliefs, and behaviors of
those with whom at-risk and symptomatic individuals interactincluding
boys and menwill be an important step in increasing the ecological validity of these programs (Austin, 2000; Levine & Smolak, 2006). Moreover,

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eating-disordered behavior appears to be increasingly common in men (Hay

et al., 2007; Striegel-Moore et al., 2009). Finally, whereas we addressed attitudes and beliefs on a range of issues that previous research suggested might
be of interest, other potentially relevant issues were no doubt neglected.
In addition to these methodological limitations, it needs to be recognized that individuals attitudes and beliefs are only one factor potentially
affecting health behaviors (Fishbein & Capella, 2006) and changing attitudes
and beliefs relating to health behaviours does not necessarily lead to behavioral change (Webb & Sheeran, 2006). Indeed, one of the disheartening
aspects of the early eating disorders prevention literature is that changes in
attitudes and beliefs have often not been accompanied by change in risk
behaviors (ODea & Abraham, 2000). On the other hand, findings from
several studies have shown that the attitudes and beliefs of individuals
with mental health problems do affect at least some behaviors, including
treatment-seeking (Jorm, Christenson & Griffiths, 2006; Meltzer et al., 2000;
Mojtabai, Olfson, & Mechanic, 2003), and there is no question that the attitudes and beliefs of the public concerning the nature of mental illness affect
the health, and health behaviors, of individuals with mental health problems (Crisp et al., 2000). We hope that the present findings will encourage
researchers to explore the potential for inclusion of specific aspects of eating disorders mental health literacy in prevention and early intervention
programs.

Study Implications
Arguably, the most notable finding of the present study is the proportion
of high-risk and symptomatic participants who appeared to believe that the
symptoms of BN are acceptable or even desirable. The perception that it
might not be too bad to have BN, when taken with the finding of high perceived prevalence, suggests that bulimic behaviors are viewed as normative
by many young women with symptoms or at risk. Whereas the ego-syntonic
qualities of anorexia nervosa are well-known (Mond, Hay, Rodgers, Owen, &
Beumont, 2005; Vitousek, Watson, & Wilson, 1998), it appears that similar thought processes may apply to aspects of more commonly occurring,
bulimic-type disorders. Although the direction of the observed associations
cannot be determined from the present study, one interpretation is that the
perception that bulimic behaviours are normative may increase the likelihood that at-risk individuals develop symptoms (Mond et al., 2004b). Hence,
one implication of the present findings is that there is a need to improve
public awareness of the nature, prevalence and adverse impact of the spectrum of disordered eating that occurs at the population level (Mond et al.,
2009).
The high proportion of participants with symptoms who reported that
someone with BN would likely be discriminated against, were the problem

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J. M. Mond et al.

to become known, is also of interest, given that perceived stigma associated

with disclosure of bulimic behaviors is a major barrier to treatment-seeking
among individuals with eating disorder symptoms (Hepworth & Paxton,
2007). Further, individuals with eating disorders may be particularly likely
to be the target of certain stigmatizing attitudes, such as the perception that
these individuals only have themselves to blame and that they should just
pull up their socks (Crisp et al., 2000). Stigmatization of this kind may
help to explain why almost one quarter of symptomatic participants in the
present study reported that they would not approach anyone for advice or
help, were they to have a problem such as the one described. Hence, a second implication of the present findings is that programs designed to promote
early and appropriate treatment seeking among individuals with symptoms
need to work in unison with population-based campaigns designed to
improve eating disorders mental health literacy at the population level (e.g.,
Jorm et al., 2006). Poor insight on the part of sufferers is also likely to be
a factor in low or inappropriate treatment-seeking (Mond, Hay, Rodgers, &
Owen, 2006b). In the present study, only half of symptomatic participants
believed that they might currently have a problem such as the one described,
despite high levels of eating disorder psychopathology and impairment in
role functioning.
Attitudes and beliefs that were common to all three groups may also be
cause for concern. The perception among women that eating disorders are
primarily problems of low self-esteem, rather than eating or mental health
problems per se, the preference for friends and family as sources of help,
and the high regard given to the use of self-help interventions, including
taking vitamins and minerals, in the treatment of BN, might all be conducive
to low or inappropriate treatment-seeking among individuals with symptoms
(Mond, Hay, Rodgers, & Owen, 2008). In addition, the high regard given to
primary care practitioners in the treatment of BN, which was also observed in
all three groups, indicates the need to evaluate and, if necessary, improve the
eating disorders mental health literacy of general practitioners, dieticians and
nutritionists and other non-specialist treatment providers (Currin, Waller, &
Schmidt, 2009; Hay, Darby & Mond, 2007).
Finally, it is instructive to consider the way in which information is
delivered to individuals with different risk/symptom profiles. Strictly speaking, the findings of the present study imply a targeted, rather than a tailored
approach, since we have identified attitudes and beliefs common to subgroups of individuals with similar profiles (Kreuter & Wray, 2003). In theory,
however, it would not be difficult to employ a tailored approach, for
example, by assessing individuals attitudes and beliefs on a pre-determined
set of domains and providing personalized feedback. Approaches of this
kind have been employed, with promising results, in other fields of health
promotion (e.g., Larimer et al., 2007), and would fit well with recent
developments in dissonance-based (Stice, Shaw, Becker, & Rohde, 2008),

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281

social-norms-based (Bergstrom & Neighbors, 2006) and media-literacy-based

(Wilsch & Wade, 2009) approaches to eating disorders prevention. Although
computer-based eating disorder prevention programs have been developed, to date these programs have been confined to selective prevention
approaches in which all participants receive the same program content
(Barr-Taylor et al., 2006).
In sum, the present findings suggest that the attitudes and beliefs of
individuals with eating disorder symptoms may differ systematically from
those of individuals at high risk, but who do not yet have symptoms, and
from those at low risk. They also indicate specific attitudes and beliefs that
may need to be addressed in universal, selective and indicated prevention
programs or, perhaps, some combination of these. Being aware of individuals characteristic modes of thinking about the nature and treatment of
eating-disordered behavior can only improve the ability to refine program
content and, in turn, increase the likelihood of success.

REFERENCES
American Psychiatric Association. (1994). Diagnostic and statistical manual of
mental disorders (4th ed.). Washington, DC: Author.
Andrews, G., Sanderson, K., Slade, T. & Issakidis, C. (2000). Why does the burden of
disease persist? Relating the burden of anxiety and depression to effectiveness
of treatment. Bulletin of the World Health Organization, 78, 446454.
Austin, S. B. (2000). Prevention research in eating disorders: Theory and new
directions. Psychological Medicine, 30, 12491262.
Barr-Taylor, C. B., Bryson, S., Luce, K. H., Cunning, D., Doyle, A. C., Abascal, L. B.
. . . Wilfley, D.E. (2006). Prevention of eating disorders in at-risk college-age
women. Archives of General Psychiatry, 63, 881888.
Bergstrom, R. L, & Neighbors, C. (2006). Body image disturbance and the social
norms approach: An integrative review of the literature. Journal of Social and
Clinical Psychology, 25, 9751000.
Currin, L., Waller, G., & Schmidt, U. (2009). Primary care physicians knowledge
of and attitudes toward the eating disorders: Do they affect clinical actions?
International Journal of Eating Disorders, 42, 453458.
Crisp, A. H., Gelder, M. G., Rix, S., Meltzer, H. I., & Rowlands, O. J. (2000).
Stigmatisation of people with mental illnessess. British Journal of Psychiatry,
177, 47.
Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disorders: Interview
or self-report questionnaire? International Journal of Eating Disorders, 16,
363370.
Fairburn, C. G, & Cooper, Z. (1993). The Eating Disorders Examination (12th ed.).
In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature, assessment and
treatment (pp. 317360). New York: Guilford Press.
Fishbein, M., & Cappella, J. N. (2006). The role of theory in developing effective
health communications. Journal of Communication, 56, S1S17.

282

J. M. Mond et al.

Hart, L. M., Jorm, A. F, Paxton, S. J., Kelly, C. M., & Kitchener, B. A. (2009). First
aid for eating disorders: Development of mental health first aid guidelines
using the Delphi consensus method. Eating Disorders: Journal of Treatment
and Prevention, 17, 357384.
Hay, P. J., Darby, A., & Mond, J. M. (2007). Knowledge and beliefs about bulimia
nervosa and its treatment: A comparative study of three disciplines. Journal of
Clinical Psychology in Medical Settings, 14, 5968.
Hay, P. J., Mond, J. M., Darby, A., & Buttner, P. (2008). Eating disorder behaviors are
increasing: Findings from two sequential community surveys in South Australia.
PLoSONE, 2, e1541.
Hay, P. J., Mond, J. M., Darby, A., Rodgers, B., & Owen, C. (2007). What are the
effects of providing evidence-based information on eating disorders and their
treatments? A randomized controlled trial in a symptomatic community sample.
Early Intervention in Psychiatry, 1, 316324.
Hepworth, N. S., & Paxton, S. J. (2007). Pathways to help-seeking in bulimia nervosa and binge eating problems: A concept mapping approach. International
Journal of Eating Disorders. 40, 493504.
Jorm, A. F., Angermeyer, M., & Katschnig, H. (2000), Public knowledge of and
attitudes to mental disorders: A limiting factor in the optimal use of treatment services. In G. Andrews & S. Henderson (Eds.), Unmet need in psychiatry
(pp. 399413). Cambridge: Cambridge University Press.
Jorm, A. F., Christensen, H., & Griffiths, K. M. (2006). Changes in depression
awareness and attitudes in Australia: The impact of Beyond Blue: The
National Depression Initiative. Australia New Zealand Journal of Psychiatry,
40, 4246.
Jorm, A. F., Korten, A. E., Jacomb, P. A., Christensen, H., Rodgers, B., & Pollitt, P.
(1997). Mental health literacy: A survey of the publics ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical
Journal of Australia, 166, 182186.
Kreuter, M. W., Strecher, V. J., & Glassman, B. (1999). One size does not fit
all: The case for tailoring print materials. Annals of Behavioral Medicine,
21, 276283.
Kreuter, M .W., & Wray, R. J. (2003). Tailored and targeted health communication:
Strategies for enhancing information relevance. American Journal of Health
Behavior, 27, S227S232.
Larimer, M. E., Lee, C. M., Kilmer, J. R., Fabiano, P. M., Stark, C. B., Geisner, I. M.,
& Neighbors, C. (2007). Personalized mailed feedback for college drinking
prevention: A randomized clinical trial. Journal of Consulting and Clinical
Psychology, 75, 285293.
Levine, M. P., & Smolak, L. (2006). The prevention of eating problems and eating disorders: Theory, research, and practice. Mahwah, NJ: Lawrence Erlbaum
Associates.
Luce, K. H., Crowther, J. H., & Pole, M. (2008). Eating Disorder Examination
Questionnaire (EDE-Q): Norms for undergraduate women. International
Journal of Eating Disorders, 41, 273276.

Eating Disorders Mental Health Literacy

283

Meltzer, H., Bebbington, P., Brugha, T., Farrell, M., Jenkins, R., & Lewis, G. (2000).
The reluctance to seek treatment for neurotic disorders. Journal of Mental
Health, 9, 319327.
Mojtabai, R., Olfson, M., & Mechanic, D. (2003). Perceived need and help-seeking
in adults with mood, anxiety, or substance use disorders. Archives of General
Psychiatry, 59, 7784.
Mond, J. M., & Hay, P. J. (2007). Functional impairment associated with eating
disorder behaviours in a community sample of women and men. International
Journal of Eating Disorders, 40, 391398.
Mond, J. M., & Hay, P. J. (2008). Public perceptions of binge eating and its treatment.
International Journal of Eating Disorders, 41, 419426.
Mond, J. M., Hay, P. J., Rodgers, B., & Owen, C. (2006a). Eating Disorder
Examination Questionnaire (EDE-Q): Norms for young adult women.
Behaviour Research and Therapy, 44, 5362.
Mond, J. M., Hay, P. J., Rodgers, B., & Owen, C. (2006b). Self-recognition of disordered eating among women with bulimic-type eating disorders: A communitybased study. International Journal of Eating Disorders, 39, 747753.
Mond, J. M., Hay, P. J., Rodgers, B., & Owen C. (2007a). Health service utilization
for eating disorders: Findings from a community-based study. International
Journal of Eating Disorders, 40, 399409.
Mond, J. M., Hay, P. J., Rodgers, B., & Owen C. (2007b). Self-report versus interview
assessment of purging in a community sample of women. European Eating
Disorders Review, 15, 403409.
Mond, J. M., Hay, P. J., Rodgers, B., & Owen, C. (2007c). Binge eating with and without the undue influence of weight or shape on self-evaluation: Implications
for the diagnosis of binge eating disorder. Behaviour Research and Therapy,
45, 929938.
Mond, J. M., Hay, P. J., Rodgers, B., & Owen, C. (2008). Eating disorders mental health literacy: What do women with bulimic eating disorders think and
know about bulimia nervosa and its treatment? Journal of Mental Health, 17,
565575.
Mond, J. M., Hay, P. J., Rodgers, B., & Owen, C. (2009). Comparing the health
burden of overweight and eating-disordered behavior in young adult women.
Journal of Womens Health, 18, 10811089.
Mond, J. M., Hay, P. J., Rodgers, B., Owen, C., & Beumont, P. J. V. (2004a). Beliefs
of the public concerning the helpfulness of interventions for bulimia nervosa.
International Journal of Eating Disorders, 36, 6268.
Mond, J. M., Hay, P. J., Rodgers, B., Owen, C., & Beumont, P. J. V. (2004b). Beliefs
of women concerning the severity and prevalence of bulimia nervosa. Social
Psychiatry & Psychiatric Epidemiology, 39, 299304.
Mond, J. M., Hay, P. J., Rodgers, B., Owen, C, & Beumont, P. J. V. (2004c). Beliefs
of women concerning causes and risk factors for bulimia nervosa. Australian
and New Zealand Journal of Psychiatry, 38, 463469.
Mond, J. M., Hay, P. J., Rodgers, B., Owen, C., & Beumont, P. J. V. (2004d). Validity
of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for
eating disorders in community samples. Behaviour Research and Therapy, 42,
551567.

284

J. M. Mond et al.

Mond, J. M., Hay, P. J., Rodgers, B., Owen, C., & Beumont, P. J. V. (2005). Assessing
quality of life in eating disorder patients. Quality of Life Research, 14, 171178.
Mond, J. M., Hay, P. J., Rodgers, B., Owen, C., Crosby, R., & Mitchell, J. E. (2006).
Use of extreme weight control behaviors with and without binge eating in a
community sample of women: Implications for the classification of bulimic-type
eating disorders. International Journal of Eating Disorders, 39, 294302.
Mond, J. M., Robertson-Smith, G., & Vitere, A. (2006). Stigma and eating disorders: Is
there evidence of negative attitudes towards individuals suffering from anorexia
nervosa? Journal of Mental Health, 15, 519532.
Mond, J. M., Rodgers, B., Hay, P. J., Korten, A., Owen, C., & Beumont, P. J. V.
(2004). Disability associated with community cases of commonly occurring
eating disorders. Australian and New Zealand Journal of Public Health, 28,
246251.
ODea, J. A., & Abraham, S. (2000). Improving the body image, eating attitudes, and
behaviours of young male and female adolescents: A new educational approach
that focuses on self-esteem. International Journal of Eating Disorders, 28,
4357.
Sanderson, K., & Andrews, G. (2002). Prevalence and severity of mental healthrelated disability and relationship to diagnosis. Psychiatric Services, 53, 8086.
Stice, E. (2002). Risk and maintenance factors for eating pathology: A meta-analytic
review. Psychological Bulletin, 128, 825848.
Stice, E., Shaw, H., Becker, C. B., & Rohde, P. (2008). Dissonance-based interventions for the prevention of eating disorders: Using persuasion principles to
promote health. Prevention Science, 9, 114128.
Striegel-Moore, R. H., Rosselli, F., Perrin, N., DeBar, L., Wilson, G. T., & May, A.
(2009). Gender differences in the prevalence of eating disorder symptoms.
International Journal of Eating Disorders, 42, 471474.
Vitousek, K., Watson, S., & Wilson, G. T. (1998). Enhancing motivation for change in
treatment-resistant eating disorders. Clinical Psychology Review, 18, 391420.
Ware, J. E., Kosinski, M., & Keller, S. D. (1996). A 12-item short-form health survey:
construction of scales and preliminary tests of reliability and validity. Medical
Care, 34, 220233.
Webb, T. L., & Sheeran, P. (2006). Does changing behavioral intentions engender
behavior change? A meta-analysis of the experimental evidence. Psychological
Bulletin, 132, 249268.
Wilsch, S. M. & Wade, T .D. (2009). Reduction of shape and weight concern in
young adolescence: A 30-month controlled evaluation of a media literacy program. Journal of the American Academy of Child and Adolescent Psychiatry, 48,
652661.

APPENDIX
The Vignette Used in the Mental Health Literacy Survey
Naomi is a 19-year-old second year arts student. Although mildly overweight
as an adolescent, Naomis current weight is within the normal range for her

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age and height. However, she thinks she is overweight. Upon starting university, Naomi joined a fitness program at the gym and also started running
regularly. Through this effort she gradually began to lose weight. Naomi
then started to diet, avoiding all fatty foods, not eating between meals,
and trying to eat set portions of healthy foods, mainly fruit and vegetables
and bread or rice, each day. Naomi also continued with the exercise program, losing several more kilograms. However, she has found it difficult to
maintain the weight loss and for the past 18 months her weight has been
continually fluctuating, sometimes by as much as 5 kilograms within a few
weeks. Naomi has also found it difficult to control her eating. While able
to restrict her dietary intake during the day, at night she is often unable
to stop eating, bingeing on, for example, a block of chocolate and several pieces of fruit. To counteract the effects of this bingeing, Naomi takes
water tablets. On other occasions, she vomits after overeating. Because of
her strict routines of eating and exercising, Naomi has become isolated from
her friends.

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