University students' confidence and importance in helping friends involved in disordered eating.
Abstract: This study examined university students' perceived confidence and importance in helping friends involved in disordered eating. A total of 419 university students completed a valid and reliable survey. Results indicated that although students felt it was important to be knowledgeable about disordered eating, the majority felt only moderately confident in helping a friend in need. Students who were female and who had a higher level of social connections felt significantly more confident than their counterparts in helping friends involved in disordered eating. Females also felt it was more important to be knowledgeable about disordered eating than did males.
Article Type: Survey
Subject: Universities and colleges (Health aspects)
Mental health (Health aspects)
Bulimia (Prevention)
Bulimia (Health aspects)
Anorexia nervosa (Prevention)
Anorexia nervosa (Health aspects)
Students (Health aspects)
Authors: Hoffman, Ashlee
King, Keith A.
PhD
Vidourek, Rebecca A.
Pub Date: 03/22/2011
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Spring, 2011 Source Volume: 26 Source Issue: 2
Product: Product Code: 8220000 Colleges & Universities NAICS Code: 61131 Colleges, Universities, and Professional Schools SIC Code: 8221 Colleges and universities
Organization: Government Agency: United States. National Institute of Mental Health
Accession Number: 308742265
Full Text: INTRODUCTION

Despite various prevention and intervention efforts, disordered eating remains a prevalent health issue in the US (Fairburn & Harrison, 2003). Approximately 24 million Americans and 70 million individuals worldwide are affected by eating disorders (National Institute of Mental Health [NIMH], 2004). Between .05% to 1% of the US population experiences anorexia nervosa, 1% to 3% experience bulimia nervosa (APA, 2001) and 2% to 5% engage in binge-eating disorder (NIMH, 2004). In addition, one in five females experience complications due to disordered eating, with 95% of all individuals with complications between the ages of 12 and 25 (NIMH, 2004). Interestingly, 15% of females exhibit attitudes and behaviors of disordered eating but have not been diagnosed (NIMH, 2004).

Up to 75% of females consider themselves to be "too fat" (APA, 2001). This may partially be due to American society's emphasis on females being thin, which may encourage many to engage in maladaptive eating behaviors. Zerbe (1995) reported that 80% of females diet before the age of 18 and the majority possesses negative feelings related to their body image at some point in their life.

The harmful physical consequences from disordered eating are well documented (Winters, Collett, Brent, & Myers, 2005) and include teeth erosions, reduced potassium levels, electrolyte imbalance, sterility, osteoporosis, heart attacks, heart irregularities, endocrine abnormalities, ruptured esophagi, seizures, anemia, ovarian failure, retinopathy, fluid imbalances, menstrual and gastrointestinal dysfunction, cardiomyopathy, and premature death (Kim, Cho, Kim, & Ko, 2009). Individuals suffering from eating disorders have the highest mortality rate than of any other illness (Sullivan, 1995). Specifically, the mortality rate of those suffering from anorexia nervosa is 12 times higher than any other cause of death for females ages 15-24 in the US. Of those suffering from anorexia nervosa, 20% will die prematurely from various health-related complications including suicide and heart problems. Malnutrition and suicide are the largest contributors to the death rate of this population (Kim et al., 2009). It is estimated that 480,000 people die each year due to issues related to eating disorders (NIMH, 2004).

Among university students, disordered eating is significantly higher among female students than same-age females in the general population (Bishop, Bauer, & Baker, 1998). While 6% of university females meet the diagnostic criteria for anorexia nervosa or bulimia nervosa, 25% to 40% display disordered eating behaviors and attitudes (Bishop, Bauer, & Baker, 1998; Tsai, Hoerr, & Song, 1998). The most common disordered eating behaviors reported by university females are binge-eating and purging (Schwitzer, Rodriguez, Thomas, & Salimi, 2001) with 25% using binging and purging as a means of weight management (NIMH, 2004). In addition, two-thirds engage in strict diets with a sizeable percent at risk for developing an eating disorder (Krahn, Kurth, Gomberg, & Drewnowski, 2005). Specifically, bulimia nervosa reaches its height around college age (18-24 years of age). Significant life changes occur when one begins college and this may place them at an elevated risk for developing an eating disorder.

Regarding social connections, studies have shown that positive social connections are associated with decreased involvement in risky behaviors (Resnick et al., 1997). However, research is needed to determine whether having a high level of social connections correlates to perceived confidence in identifying disordered eating behaviors in peers. Resnick and colleagues (1997) described social connectedness as involving warm and caring relationships within the family, school, and community. Approximately half of Americans report knowing someone involved in disordered eating (Fairburn & Harrison, 2003). With this in mind, friends and family members can play an important role in the early detection of this problem and the appropriate referral to professionals for treatment and recovery. To date, there have been no published studies examining university students' perceived confidence in identifying peers involved in disordered eating.

Since females are at increased risk for disordered eating, (United States Department of Health and Human Services, 2006), they may have increased confidence in identifying friends also involved. This could have direct implications for professionals interested in developing prevention programs and interventions. However, no study has currently examined this research question. In addition, gaps in the research currently exist regarding the relationship between disordered eating detection and the extent of social connections, as well as whether confidence in disordered eating detection differs between males and females. When individuals feel positively connected to important others they have potential avenues for support and assistance. They also have individuals readily available with whom they can discuss personal problems and issues.

The purpose of this study was to examine university students' perceived confidence and importance in helping friends involved in disordered eating. In addition, this study investigated whether confidence and importance differed based on sex and extent of social connections. This study sought to fill current gaps in the literature regarding disordered eating. The findings of this study are especially important for health educators, prevention specialists and those interested in trying to prevent disordered eating among university students.

METHODS

PARTICIPANTS

A sample of students from a Midwestern university served as the participants in this study. A power analysis indicated that based on a total population of 30,417 students and a confidence level of 95%, a sample size of at least 347 students was required. Participants were students currently enrolled in 32 fitness and introductory level health courses on main campus during the 2010 spring quarter. The sample was representative of the overall population based on the demographics shown in Table 1. Participation was voluntary and no incentives were offered.

INSTRUMENTATION

A 2-page survey was developed based on a comprehensive review of the literature, previous survey instruments, and discussions with professionals specializing in the prevention and treatment of disordered eating. This survey examined students' perceived confidence and importance regarding disordered eating. A Perceived Confidence subscale requested students to rate how strongly they agreed or disagreed with five confidence items via a 5-point Likert-type scale (1 = Strongly disagree; 5 = Strongly agree). Similarly, a Perceived Importance subscale requested students to rate how strongly they agreed or disagreed with five importance items via a 5-point Likert-type scale (1 = Strongly disagree; 5 = Strongly agree). To assess the extent of social connections, students were requested to check yes or no to 15 items regarding their involvement with important others. A Demographic section consisted of seven items that required students to respond by checking the appropriate box.

Validity and reliability of this survey were established using a variety of methods. Face and content validity were established by developing the survey based on comprehensive review of the literature and distributing it to a panel of experts for review. The panel consisted of experts in disordered eating, mental health, university student health and survey research. Experts were sent the survey and a cover letter explaining the study purpose and research questions. All suggested revisions were discussed by the research team and incorporated into the final instrument.

Stability reliability was established by administering the survey to a sample of 30 university students on two separate occasions, one week apart. Pearson correlation coefficients were computed for parametric items while Kendall's tau-b coefficients were computed for nonparametric sections, each yielding coefficients > .80, thus demonstrating reliability. Internal consistency reliability was established by computing Cronbach alphas for each of the parametric subscales, yielding alphas > .81.

PROCEDURES

Prior to study implementation, the study was approved by the Institutional Review Board (IRB). Following this approval, the research team randomly selected instructors of fitness and introductory health courses from the University's list of course offerings for the 2010 spring quarter. The primary investigator emailed instructors the survey and a cover letter explaining the study purpose and requested permission to distribute the survey in their spring 2010 courses. Those who agreed were asked to respond with appropriate dates and times of the classes and number of students in each class. Surveys were distributed for each class during class time in May and June of 2010. Students in a total of 32 introductory level fitness and health classes were surveyed.

Students present in the classes on the day of survey administration were requested to complete the survey. The survey was introduced at the beginning of each class. The primary investigator described the purpose of the study to the students and described the confidential nature of the study. Students were assured that their participation was completely voluntary and by completing the survey they granted consent to have their responses used in the study. All students received a survey with a cover letter restating and a survey. The survey took approximately five to ten minutes to complete. The primary investigator preserved anonymity of the surveys by instructing participants to refrain from putting their names or any other identifying information on the survey. Participants were instructed to place surveys face-down in an envelope that was offered at the front of each classroom. The researcher counted each set of surveys in order to keep accurate totals of completed surveys. The researcher then sealed each envelope after all surveys were collected for each class. Surveys were stored in a locked personal file cabinet in the researcher's locked personal office. All surveys were shredded following data analysis.

DATA ANALYSIS

All data was analyzed using the Statistical Package for the Social Science (SPSS Version 16). Descriptive statistics (frequencies, means, standard deviations, ranges) were used to describe the demographics and background information. Multivariate analyses of variance (MANOVAs) were computed to determine whether students' perceived confidence and importance differed based on sex, current involvement in disordered eating, and extent of social connections. The alpha level of significance was established at .05.

RESULTS

A total of 428 out of 432 students completed surveys (99% response rate). Most participants were female (59.1%) and Caucasian (78.3%) (Table 1). Grade levels included freshman (15.7%), sophomores (21%), juniors (13.4%), seniors (35.5%), and other (5.1%). Ages ranged from 17 to 37 (M = 21.44, SD = 2.63). Participants' reported grade point average ranged from 1.0 to 4.0 (M = 3.3, SD = 0.45). Majors were characterized into three different categories: Non Health Education (78.5%), Health Education (13.8%), and Psychology (4%). The majority of participants were employed part time (51.9%).

Regarding social connections, students most frequently reported that they enjoyed spending time with their family (94.6%), considered their family to be supportive (93.0%), and felt close to their family (92.3%) (Table 2). Students least frequently reported that they were involved in a campus athletic activity (38.1%), were involved in a religious organization (43.2%), and were involved in a campus organization (57.2%) or athletic activities outside of campus (57.2%).

PERCEIVED CONFIDENCE IN HELPING FRIENDS INVOLVED IN DISORDERED EATING

Results indicated that participants felt moderately confident in helping friends involved in disordered eating (Table 3). Means ranged from 3.43 for confidence in knowing what to do if they think a friend has an eating disorder to 3.82 for confidence in identifying a friend with a eating disorder. A multivariate analysis of covariance (MANCOVA) was conducted to determine whether students' perceived confidence differed based on sex. Results indicated that perceived confidence differed significantly between males and females, F(5, 408) = 4.813, p < .001. Univariate F-tests revealed that females felt significantly more confident than males in recognizing a friend who has an eating disorder (M = 3.92 VS M = 3.66, respectively) and in knowing what to if a friend had an eating disorder (M = 3.49 VS M = 3.32, respectively). In contrast, males felt more confident addressing disordered eating in females (M = 3.90 VS 3.73, respectively) and obtaining information (M = 3.86 VS M = 3.76, respectively). Both male and females felt similar in their confidence in taking appropriate steps to help a friend with an eating disorder (M = 3.79).

A social connections score was computed based on the 15 questions asked to assess the extent of participants' social connections. Scores ranged from 0-15 and were subsequently dichotomized into high and low categories based on a median split. A MANOVA was performed to determine whether participants' perceived confidence differed significantly based on level of social connections. Results showed a significant difference in participants' perceived confidence in helping friends with disordered eating based on the extent of social connections, F(5, 408) = 3.352, p = .006. Univariate F-tests revealed that students with a high level of social connections reported higher confidence than students with a low level of social connections in recognizing a friend with an eating disorder (M = 3.84 VS M = 3.79, respectively), that they knew what to do if they thought a friend had an eating disorder (M = 3.50 VS M = 3.30, respectively), that they knew the appropriate steps to help a friend with an eating disorder (M = 3.86 VS M = 3.69, respectively), and that they could obtain information on campus about eating disorders (M = 3.88 VS M = 3.68).

PERCEIVED IMPORTANCE IN KNOWING HOW TO HELP FRIENDS INVOLVED IN DISORDERED EATING

Results indicated that participants felt that it was important to extremely important to know how to help friends involved in disordered eating (Table 4). Means were especially high for participants in feeling it is important to help a friend involved in disordered eating (M = 4.59), feeling it is important to know the risk factors for disordered eating (M = 4.44), feeling it is important to know the steps to take when someone has an eating disorder (M = 4.42), and feeling it is important to know the warning signs for disordered eating (M = 4.36). A MANOVA indicated that participants' perceived importance differed based on sex, F(5, 408) = 3.406, p = .009. Univariate F-tests revealed that females felt it was significantly more important than did males to know the warning signs for disordered eating (M = 4.45 VS M = 4.25, respectively), know the risk factors for disordered eating (M = 4.49 VS M = 4.36), know the steps to take when someone is involved in disordered eating (M = 4.47 VS M = 4.35), and to feel it is important to help an individual involved in disordered eating (M = 4.63 VS M = 4.53, respectively).

A MANOVA was also performed to determine whether participants' perceived importance differed based on the extent of their social connections. Results showed no significant difference in perceived importance between those with a high level of social connections and those with a low level of social connections, F(5, 408) = 1.555, p = .185.

DISCUSSION

The present study found that students felt only moderately confident in their ability to help friends involved in disordered eating. This finding is important in light of previous research conducted by the National Eating Disorder Association (2006) which found that just more than half (57.6%) of individuals reported talking with a friend experiencing disordered eating. While some students feel confident in their abilities, it appears that a sizeable percentage lack confidence and therefore do not speak with friends in need of help. Such findings are quite concerning since many university students will first show warning signs of disordered eating to their peers and wish to talk to peers about their personal issues. This reinforces the importance of university students being properly informed about this issue in order to appropriately intervene and help friends seek assistance from a mental health professional.

Females felt significantly more confident than males in helping friends involved in disordered eating. No previously published studies were found that had specifically examined differences in confidence levels based on sex. However, the difference found in the present study may largely be due to the fact that females are more likely to personally experience disordered eating. Research suggests that approximately 90% of individuals with eating disorders are females between the ages of 12 and 25 (United States Department of Health and Human Services, 2006). In addition, females may be more likely to simply talk to friends and express concern about personal and mental health issues. Gender differences have been identified in interpersonal communication, with males accepting and exhibiting societal messages to abandon expression of feelings while emphasizing autonomy, self-reliance, and independence (Belle, 1987). Conversely, females tend to cultivate increased care and concern to their peers when communicating (Olson & Shultz, 1994). Such issues may be underlying factors which help to explain this difference in confidence levels between males and females. Based on the findings of this study, it appears that while both males and females would benefit from increased education on how to help friends involved in disordered eating, efforts are clearly needed to enhance males' self-efficacy in addressing this issue. Specific educational programs could be developed to help males feel more comfortable in expressing their feelings (Blier & Blier-Wilson, 1989), especially in regards to how their feelings relate to overall health and well-being of peers.

The present study also found that students who had a high level of social connections felt significantly more confident than their counterparts in helping friends involved in disordered eating. Previous research has not specifically explored this issue, however social relationships have been consistently documented as important to one's health and well-being (Bruhn, 2005). In addition, individuals possessing more social connections tend to interact more with others, which may in turn result in their feeling more comfortable and competent to help friends in need. Future research is clearly needed to more thoroughly examine this area. However, several studies have shown the importance of social connections to help college students in addressing mental and emotional health issues (Felsten, 1998; Misra & McKean, 2000).

The present study also found that university students felt that it was important to know the warning signs, risk factors and appropriate intervention steps for disordered eating. Overall, students felt that it was extremely important to help friends involved in disordered eating. This finding is important to note since such a large percentage of students know friends who are experiencing these issues. Unfortunately, while students feel it is important to be knowledgeable on how to help friends in need, many do not feel confident in their abilities to appropriately help, as noted above. As students feel this issue is of such importance, it appears logical that campus based educational modules on disordered eating would be well received. Efforts are also needed to combat societal and peer pressures overemphasizing unrealistic and excessively thin body sizes among university students. Research has shown that perceived peer pressure to be thin can greatly increase the likelihood of developing or further encouraging eating disorders (Tantleff-Dunn & Gokee, 2004). Increased student awareness of the facts surrounding these issues may help students to feel more inclined to appropriately address disordered eating among their friends.

Results of the present study specifically indicated that females viewed the issue of helping friends involved in disordered eating as more important than did males. This could again be due to the fact that eating disorders are more prevalent among females (NADA, 2005). This could be due to the fact that males are less likely than females to address health issues and health concerns (Denton, Prus, & Walters, 2004). Increased education on the importance and prevalence of this health problem is warranted. Early detection and support would be extremely beneficial in reducing disordered eating among university students (Becker, Franko, Nussbaum, & Herzog, 2004).

CONCLUSIONS AND RECOMMENDATIONS

Research indicates that early detection of disordered eating is of vital importance. Like any risky behavior, disordered eating is more difficult to treat the longer the individual engages in that behavior. By informing university students about the warning signs, risk factors and appropriate intervention techniques, rates of disordered eating among university students may be reduced. This study found that students were interested in the subject of disordered eating and found it to be highly important. Unfortunately, a sizeable percentage of students did not feel confident helping friends in need. Perhaps taking steps to educate and increase students' awareness of this issue could help assist students with disordered eating. Currently, prevention and educational programs on disordered eating are limited in the college setting (Stice & Ragan, 2002). Thus, increased efforts are necessary. Programs should aim towards increasing students' confidence levels in helping friends involved in disordered eating. This aim may be realized through the use of group discussions, skill-building activities, role-plays and mock scenarios.

The following limitations to the present study should be noted. First, as data was cross-sectional in nature, causal relationships could not be determined. Second, the self-reported nature of the survey instrument may have elicited some socially desirable responses from students. Third, since the study involved self-reported data, the results are reliant upon students' honesty and accuracy in answering items. Fourth, the monothematic design of the survey instrument may have resulted in a response-set bias in some participants. Lastly, the study sample was comprised of students from a Midwestern university. Therefore, caution should be exercised in generalizing study findings to students in other grade levels or geographical locations.

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Ashlee Hoffman, MA Keith A. King, PhD, MCHES Rebecca A. Vidourek, PhD, CHES

Ashlee Hoffman, MA, is a graduate assistant at Health Promotion & Education, University of Cincinnati. Keith A. King, PhD, MCHES, is a professor at Health Promotion & Education, University of Cincinnati. Rebecca A. Vidourek, PhD, CHES, is an assistant professor at Health Promotion & Education, University of Cincinnati. Corresponding author: Keith A. King, PhD, MCHES, Health Promotion & Education, University of Cincinnati, Cincinnati, OH 45221-0068, Phone 513-556-3859, Fax 513-556-3898, Email keith.king@uc.edu.
Table 1. Demographics and Background Characteristics of Participants

Characteristic            n     %

Sex
  Male                   166   38.8
  Female                 253   59.1

Grade
  Freshman               67    15.7
  Sophomore              90     21
  Junior                 90     21
  Senior                 151   35.5

Ethnicity
  African American       42    9.8
  Asian                  21    4.9
  Hispanic/Latino         5    1.2
  White/Caucasian        335   78.3
  Multi-Racial           10    2.3
  Other                   4     .9

GPA
  4.0-3.5                182   42.5
  3.0-3.49               164   38.3
  2.5-2.99               53    12.4
  2.0-2.49               11    2.6
  1.5-1.99                3     .7
  1.0-1.49                1     .2

Major
  Non Health Education   336   78.5
  Health Education       59    13.8
  Psychology             17     4

Employment Status
  Full-time              79    18.5
  Part-time              222   51.9
  Unemployed             117   27.3

N = 428; Percents based on valid percents;
Missing value excluded

Table 2. Extent of Social Connections among Participants

                                                           n     %

I enjoy spending time with my family                      405   94.6
I consider my family to be supportive                     398   93.0
I am close to my family                                   395   92.3
I engage in activities with my family                     389   90.9
  (other than holidays)
I enjoy/enjoyed school                                    385   90.0
I feel/felt successful in school                          377   88.1
I talk to members of my family about important issues     368   86.0
I feel connected to my community                          331   77.3
I consider myself to have a lot of friends in school      320   74.8
I volunteer in my community                               283   66.1
I am involved in an athletic activity outside of campus   245   57.2
I am involved in a community organization                 245   57.2
I am involved in a religious organization                 185   43.2
I consider myself to have a lot of friends                357   38.4
  in my community
I am involved in a campus athletic activity               163   38.1

Table 3. Perceived Confidence in Helping Friends Involved in
Disordered Eating

I feel confident that I ...                            M      SD

Can recognize a friend who has an eating disorder.   3.82   .898
Can talk to a friend about their eating disorder.    3.79   .928
Can take appropriate steps to help a friend that     3.79   .898
  has an eating disorder.
Can obtain information on campus about               3.79   .963
  eating disorders.
Know what to do if I think a friend has an           3.43   1.002
  eating disorder.

N = 428; Missing value excluded.

Means based on 5-point scale (1 = Strongly Disagree, 2 = Disagree,
3 = Neutral, 4 = Agree, 5 = Strongly Agree)

Table 4. Perceived Importance in Being Knowledgeable
Regarding Disordered Eating

I think ...                                         M      SD

It is important to help an individual with an     4.59   .572
  eating disorder.
It is important to know the risk factors for      4.44   .607
  eating disorders.
It is important to know the steps to take when    4.42   .636
  someone has an eating disorder.
It is important to know the warning signs for     4.36   .636
  eating disorders.
Eating disorders are a major problem on college   3.37   .891
  campuses

N = 428; Missing value excluded.

Means based on 5-point scale (1 = Strongly Disagree, 2 = Disagree,
3 = Neutral, 4 = Agree, 5 = Strongly Agree)
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