Eating disorders mental health literacy in Singapore: beliefs of young adult women concerning treatment and outcome of bulimia nervosa

Original Article

Eating disorders mental health literacy inSingapore: beliefs of young adult women

concerning treatment and outcome ofbulimia nervosaeip_156 39..46

Anna Chen,1 Jonathan M. Mond2 and Rajeev Kumar3

1Department of Child and AdolescentPsychiatry, Institute of Mental Health,Singapore; 2School of Biomedical andHealth Sciences, University of WesternSydney, Campbelltown, New SouthWales; and 3Academic Unit of Psychiatry,The Canberra Hospital & The AustralianNational University, Canberra, AustralianCapital Territory, Australia

Corresponding author: Ms Anna Chen,Department of Child and AdolescentPsychiatry, Institute of Mental Health,Singapore, Building, Buangkok GreenMedical Park, 10 Buangkok View, 539747Singapore. Email: [email protected]

Received 31 May 2009; accepted 19October 2009

Abstract

Aim: We examined the eating disor-ders ‘mental health literacy’ of youngadult women in Singapore.

Methods: A self-report questionnairewas completed by 255 womenrecruited from three university cam-puses. A vignette of a fictional(female) person exhibiting the char-acteristic features of bulimia nervosawas presented, followed by a series ofquestions concerning the treatmentand outcome of the problemdescribed. A measure of eating disor-der symptoms was included in thequestionnaire.

Results: Consulting a primary carepractitioner, counsellor or psycholo-gist; seeking the advice of a (female)family member or friend; gettingadvice about diet and nutrition; and

taking vitamins and minerals were theinterventions most often consideredhelpful. Participants were less posi-tive about the benefits of psychiatrist-sand were ambivalent about the useof psychotropic medication. Partici-pants’ mothers were most often con-sidered helpful as they are an initialsource of help. Among participantswith a high level of eating disordersymptoms, recognition of an eatingproblem was poor. A minority of par-ticipants believed that treatmentwould result in full recovery.

Conclusions: Aspects of the eatingdisorders mental health literacy ofyoung Singaporean women may beconducive to low or inappropriatetreatment seeking. Health promotionprogrammes need to target not onlyat-risk individuals, but also theirfamily members and social circle.

Key words: bulimia nervosa, eating disorder, mental health literacy,Singapore.

INTRODUCTION

In recent years, findings from cross-culturalresearch have increased recognition that individualsin certain non-Western countries may be as suscep-tible to eating disorders as those in Western coun-tries.1,2 As might be expected, the most dramaticchanges have occurred in those countries – such asHong Kong, Thailand, Japan, Korea and Singapore –where exposure to Western influence and culturehas been most pronounced.1,2 Findings from severalrecent studies suggest that levels of body dissatis-faction, preoccupation with thinness and other

aspects of eating-disordered behaviour in these‘newly industrialized’ countries may be as high as,if not higher than, those observed in Westerncountries.3–9

Given the high prevalence of eating-disorderedbehaviour at the population level, it is important tounderstand issues regarding unmet need for treat-ment and factors that may affect treatment-seekingbehaviour.10 In the absence of rigorous epidemio-logical data from Asian populations, it is difficultto know the extent of any unmet need for treat-ment among individuals with eating disordersymptoms in these regions. However, large-scale

Early Intervention in Psychiatry 2010; 4: 39–46 doi:10.1111/j.1751-7893.2009.00156.x

© 2010 The AuthorsJournal compilation © 2010 Blackwell Publishing Asia Pty Ltd

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epidemiological studies of eating-disorderedbehaviour in Western nations have consistentlyshown that the majority of individuals with eatingdisorders does not receive mental health care,despite high levels of distress and functional impair-ment among sufferers.11,12 It is reasonable to positthat unmet need for treatment among individualswith eating disorders and other mental health prob-lems may be similarly high in newly industrializedAsian countries.

One factor believed to be conducive to low orinappropriate treatment seeking among individualswith eating disorders – and mental health problemsmore generally – is their knowledge and beliefsabout treatment and the treatment process, an areaof investigation that has been referred to as ‘mentalhealth literacy’ (MHL).13,14 Studies have shown thatthe public is ambivalent about the use of mentalhealth professionals in the treatment of eating dis-orders and that this may be a factor in low or inap-propriate treatment seeking among individuals withsymptoms.15,16 Ambivalence of this kind may bemore pronounced in newly industrialized Asiancountries, where the use of traditional medicinemay conflict with Western notions of evidence-based treatment.17–19

The goal of the present study was to examineeating disorders MHL in Singapore, an island nation(of approximately 5 million people) in South-EastAsia that has experienced rapid economic growth inrecent years and, in turn, increased exposure toWestern popular culture and values.17,20 We focusedon bulimia nervosa (BN), as BN and variants of BN,such as binge-eating disorder (BED) and ‘purging’disorder, are common, disabling and associatedwith particularly low rates of treatment.12,21,22 This isdespite the availability of efficacious treatment inthe form of specific psychotherapy.23,24

METHOD

Study design and participants

Participants were 255 young adult women recruitedfrom three university campuses in the city ofSingapore. They comprised first-year psychologystudents and first or second-year business and engi-neering students. A brief questionnaire addressingeating disorders MHL as well as eating disordersymptoms was completed by participants as part oftheir weekly lectures, with the prior permission ofthe lecturers concerned.

Only female students were approached for par-ticipation. This decision was made, in part, because

bulimic-type eating disorders are more commonamong women than men. In addition, we wanted tobe able to compare findings from the present studywith those of previous research in Australianwomen.15,16 Young adult women were chosenbecause early adulthood is the peak age of onset forbulimic-type eating disorders.11,25

Upon arrival at their lectures, (female) studentswere approached to participate in a study of atti-tudes and beliefs about eating concerns involvingcompletion of a brief, anonymous questionnaire.Students who agreed to participate were given aninformation sheet, a consent form, and the studyquestionnaire. Upon completion of the question-naire, attention was drawn to the section of theinformation sheet in which the contact details of theresearcher and those of the University CounsellingServices were provided. Participants interested inobtaining further information about the studyand/or advice or treatment in relation to aneating problem were invited to make use of thisinformation.

Participants who were psychology students at oneof the campuses (James Cook University) receivedcredit points in exchange for participation. Other-wise, there was no remuneration. Ethics approvalfor all aspects of the study design and procedure wasobtained from the James Cook University HumanEthics Committee. The research was conducted in2008.

A total of 260 questionnaires were distributed overa 1-month period. None of the students approacheddeclined to participate or withdrew from the study.However, five questionnaires were returned uncom-pleted. Data from the remaining 255 participantswere analysed. The vast majority of participants(n = 228, 90.8%) indicated that they were Sin-gaporean nationals. The mean (standard deviation)age of participants was 19.0 (1.8) years. Their mean(standard deviation) body mass index (kg m2) was19.5 (2.5).

The MHL survey

The MHL survey was modelled on the work of Jormand colleagues,14 with appropriate modifications forthe study of eating-disordered behaviour and foruse in a self-report format.15,16,26 The surveyemployed in the present study was designed toreplicate the previous work of Mond and colleaguesin Australian women.15,16,26

A vignette of a fictional young woman (‘Kelly’)who met the diagnostic criteria for BN (purgingsubtype), as stated in the fourth edition of the Diag-nostic and Statistical Manual of Mental Disorders,27

Eating disorders mental health literacy

40 © 2010 The AuthorsJournal compilation © 2010 Blackwell Publishing Asia Pty Ltd

was presented. Care was taken to ensure that thedistinctive features of the disorder were conveyedwhile avoiding the use of overly technical language.The vignette is given in Appendix I.

Participants were first asked, ‘What do you thinkis Kelly’s main problem?’ A list of options was given,and participants were instructed to choose only oneoption. The options were the following: ‘anorexianervosa’ (AN), ‘BN’, ‘BED/problem’, ‘poor diet’, ‘anutritional deficiency’, ‘an exercise disorder/problem’, ‘low self-esteem/lack of self-confidence’,‘depression’, ‘loneliness’, ‘an anxiety disorder/problem’, ‘stress’, ‘mental illness’ and ‘no realproblem, just a phase’. The same ordering ofresponse options, which had initially been chosenat random, was used for all participants.

Participants were next asked to rate the helpful-ness of a number of possible interventions withineach of three broad categories – people, treatments/activities and medicines/pills – by indicatingwhether they believed each intervention would be‘helpful’, ‘harmful’ or ‘neither’ (helpful nor harmful)in the treatment of Kelly’s problem (see Table 2).

Participants were also asked to rate the interven-tion, within each category, that they believed wouldbe most helpful for Kelly; which person they wouldbe likely to approach first, were they to have aproblem such as the one described; and also, whatthey believed would be the most likely outcome forKelly were she to receive the intervention con-sidered most likely to be helpful in each category.Response options for the latter question were asfollows: ‘full recovery with no further problems’, ‘fullrecovery but the problem will likely reoccur’, ‘partialrecovery’, ‘partial recovery, but the problem willlikely reoccur’, ‘no improvement’ and ‘get worse’.

The questionnaire ended with a questionaddressing participants’ personal experience of aneating problem, namely: ‘Do you think that youmight currently have a problem such as the onedescribed’? and ‘Do you think that you have everhad a problem such as the one described’?

Assessment of participants’ eatingdisorder symptoms

Participants’ levels of eating disorder psychopa-thology were assessed using the Eating DisorderExamination-Questionnaire (EDE-Q).28 The EDE-Qis a 36-item self-reported measure derived from theEDE interview,29 the latter being widely regarded asthe measure of choice in the field. The EDE-Qfocuses on the past 28 days and is scored using aseven-point, forced-choice, rating scheme. Subscalescores – relating to dietary restraint, and eating,

weight and shape concerns – and a global score arederived from 22 items addressing attitudinal aspectsof eating disorder psychopathology.30 Scores oneach subscale (and global scores) range from 0 to 6,with higher scores indicating higher symptomlevels. The remaining items assess the occurrenceand frequency of eating disorder (i.e. binge-eatingand extreme weight control) behaviours. Theseitems do not contribute to subscale scores. Highlevels of agreement between self-report (EDE-Q)and interview (EDE) assessment of the attitudinalaspects of eating disorder psychopathology havebeen demonstrated in a range of study populations,including community-based samples of youngadult women.31

In order to examine the effects of eating disordersymptoms on responses to specific questions, prob-able cases of eating disorders were identified usingan operational definition that we have found usefulin previous research, namely, the occurrence ofextreme weight or shape concerns in conjunctionwith any regular eating disorder behaviour.26,32

‘Extreme weight or shape concerns’ were defined asa score of 5 or 6 on either of the EDE-Q items assess-ing ‘importance of weight’ and ‘importance ofshape’.33 Eating disorder behaviours assessed werebinge-eating, self-induced vomiting, misuse of laxa-tives or diuretics, extreme dietary restriction andexcessive exercise.30

Thirty-one participants (12.2%) were identified asprobable eating disorder cases according to thisdefinition. The term ‘eating disorder cases’ shouldbe interpreted with caution, as self-report assess-ment of eating disorder behaviours (as opposed tothe attitudinal features assessed by the EDE-Q sub-scales) is generally considered less reliable thaninterview assessment, and we did not have anyinformation relating to clinical significance. Never-theless, the operational definition employed is likelyto have identified a subgroup of participants withhigh levels of eating disorder psychopathology.32

Statistical analysis

Data are presented as the percentage (%) ofparticipants endorsing specific responses for eachquestion. For questions concerning the perceivedhelpfulness of particular interventions, responseswere recoded (helpful = 1; harmful = -1; neither =0). Mean ratings for each option were then exam-ined as a function of eating disorder psychopathol-ogy (i.e. ‘case’ and ‘non-case’) and recognition of theproblem using non-parametric methods, namely,Mann–Whitney U-tests. Associations betweeneating disorder psychopathology and problem

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recognition and responses to the questions address-ing the most helpful interventions, the person mostlikely to be approached in the first instance andKelly’s likely prognosis were examined by meansof chi-squared tests. In view of the multiplecomparisons, only findings significant at the 0.01level are reported.

RESULTS

Beliefs about the ‘main problem’, helpfulnessof interventions and likely prognosis

As can be seen in Table 1, the modal response to thequestion concerning Kelly’s main problem was lowself-esteem (38.0%). Fifteen per cent (14.5%) of par-ticipants correctly labelled Kelly’s problem as BN,14.1% of participants believed that Kelly’s mainproblem was AN, and 11.0% of participants believedthat Kelly’s main problem was BED. Together, theseresponses accounted for 77.6% of all responses

The percentages of participants who rated each ofthe interventions in each subcategory – people,treatment/activity and medication/substance – ashelpful, harmful or neither (helpful nor harmful),for Kelly, are shown in Table 2. The items arearranged from the highest frequency to the lowestfrequency according to the ‘helpful’ option.

It is apparent that primary care practitioners,(female) friends and family members, and psy-chologists were the people considered most likely tobe helpful for Kelly, whereas obtaining adviceabout diet or nutrition, counselling, cognitive–behavioural therapy (‘working with a mental healthprofessional to change thoughts and behaviours’)and talking to a friend or a family member werethe activities considered most likely to be helpful.

Of the medicines/pills included, only vitamins andmineral supplements were considered to be helpfulby a majority of participants. The modal response tothe question concerning the person participantswould be most likely to approach first, were they tohave a problem such as the one described, was theirmother (26.3%; Table 2).

Participants’ beliefs about Kelly’s likely prognosis,given the help considered most likely to be helpfulwithin each category, are summarized in Table 3. Itcan be seen that the modal response for the ‘people’and ‘treatments/activities’ categories was ‘fullrecovery, but the problem will likely reoccur’,whereas the modal response for the ‘medicines/pills’ category was ‘partial recovery’.

Associations between recognition of the‘main problem’ and responses

Compared with participants who believed thatKelly’s main problem was low self-esteem (38.05),participants who recognized Kelly’s main problemas being an eating disorder (i.e. BN, AN or BED)(39.6%) were (i) less likely to rate talking to a gyminstructor about how to exercise to lose weight as‘helpful’ (27.7% vs. 50.5%; z = -3.32, P < 0.01), and(ii) more likely to rate the use of a commercialweight-loss programme as harmful (63.4% vs.46.4%; z = -2.68, P < 0.01). There were no othersignificant differences between these groups.

Association between eating disorderpsychopathology and responses

Participants identified as probable eating disordercases (n = 31) were (i) more likely to rate ‘a gyminstructor’ (67.7% vs. 38.4%; z = -2.85, P < 0.01) as‘helpful’, and (ii) less likely to rate ‘a self-help supportgroup’ (35.5% vs. 67.4%; z = -3.40, P < 0.01), ‘apsychiatrist’ (45.2% vs. 70.5%; z = 2.98, P < 0.01),‘counselling’ (64.5% vs. 84.8%; z = -2.75, P < 0.01)and ‘talking about the problem to a friend or familymember’ (58.1% vs. 85.7%; z = -3.88, P < 0.01) ashelpful than non-cases (n = 224).

There was a tendency for probable eating disordercases to be more likely to identify Kelly’s ‘mainproblem’ as being low self-esteem (65.4% vs. 46.5%)(and less likely to identify the main problem as aneating disorder: 34.6% vs. 53.5%) than non-cases(c = 3.22, P = 0.07). Of the 31 probable eating disor-der cases, less than one third (n = 9, 29.0%) believedthat they might currently have a problem such asthe one described.

TABLE 1. Recognition of Kelly’s ‘main problem’: percentage (%)of participants (n = 255) choosing each response option

Response option %

Low self-esteem 38Bulimia nervosa 14.5Anorexia nervosa 14.1Binge-eating disorder 11Poor diet 6.2Stress 5.1Depression 4.7Anxiety disorder/problem 2.4Nutritional deficiency 2Exercise disorder/problem 0.8Mental illness 0.8No real problem/‘just a phase’ 0.4



TABLE 2. Perceived helpfulness of interventions for bulimia nervosa: percentages of participants endorsing options within eachcategory – people, treatments/activities and medicines/pills

Interventions Helpful(%)

Neither(%)

Harmful(%)

Mosthelpful

(%)

Firstapproach

(%)

People who might be helpfulCounsellor 87.5 10.6 2 18.3 16.1Dietician/nutritionist 86.7 11 2.4 19.5 9.8Psychologist 83.1 14.1 2.7 15.9 9General practitioner/family doctor 78.4 20.8 0.8 10.8 11Close friend (female) 78.4 19.2 2.4 11.2 18Mum 77.3 20.8 2 9.6 26.3Sister 72.5 26.7 0.8 0.8 3.9Psychiatrist 67.5 25.9 6.7 5.2 1.2Dad 64.2 31.9 3.9 0.4 0.4Self-help support group 63.5 32.5 3.9 3.6 2.4Brother 45.5 50.6 3.9 0 0Close friend (male) 45.1 47.5 7.5 1.2 0.4Social worker 42.7 52.5 4.7 0 0.4Kelly’s gym instructor 42 41.2 16.9 3.6 1.2

Treatments/activities that might be helpfulGetting advice about diet or nutrition 83.1 11.8 5.1 15.9 –Counselling 82.4 17.3 0.4 19.5 –Talking about the problem with a friend or a family member 82.4 15.3 2.4 10.4 –Obtaining more information about the problem and available services 75.3 21.2 3.5 3.2 –Working with a mental health professional to change thoughts and behaviours 71.4 22.4 6.3 17.9 –Finding some new hobbies 69.4 29 1.6 8 –Relaxation therapy/meditation 62 35.7 2.4 3.6 –Assertiveness/social skills training 48.6 48.2 3.1 0.4 –Getting advice on losing weight 46.7 24.7 28.6 6.4 –Reading a self-help book/treatment manual 45.9 48.6 5.5 2.4 –Going to a community health centre 39.6 57.6 2.7 0 –Talking to a gym instructor 39.6 23.1 37.3 3.2 –Going to a private hospital 36.1 57.6 6.3 0.8 –Going to a public hospital 35.3 56.9 7.8 1.2 –Calling a mental health helpline 32.9 47.8 19.2 0 –Talking to a religious leader 25.1 59.2 15.7 1.2 –Trying a commercial weight-loss programme 14.9 33.7 51.4 0.4Consulting a spiritual healer 14.5 61.2 24.3 0 –Trying to deal with the problem on her own 11 24.3 64.7 0 –

Medicines/pills that might be helpfulVitamins or mineral supplements 84.3 13.3 2.4 66.9 –Medication to help one relax 39.6 48.2 12.2 8.3 –Antidepressant medication 38 39.2 22.7 16.9 –Tonics and herbal medicines 38 54.5 7.5 6.7 –Dieting pills 5.5 18.8 75.7 1.2 –

TABLE 3. Beliefs about prognosis of bulimia nervosa: percentages of participants endorsing different possible outcomes for Kelly wereshe to receive the help considered most helpful within each category

People Treatment/activity Medication/substance

Full recovery with no further problems 23.5 28.2 11Full recovery, but the problem will likely reoccur 42.4 40.8 28.2Partial recovery 22 18.8 40Partial recovery, but the problem will likely reoccur 11.4 11 13.3No improvement 0.8 1.2 7.5Get worse 0 0 0

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DISCUSSION

We examined beliefs about the treatment of BNamong young adult women in Singapore. Generally,the findings were similar to those of research con-ducted in Australia and other Western countries.Thus, primary care practitioners, family membersand friends, and lifestyle changes, such as gettingmore information about the problem and availableservices, were the interventions viewed mostfavourably, whereas participants were less positivetowards psychiatrists and were ambivalent aboutthe use of prescription medication. Participantswere also ambivalent about the prospects of fullrecovery given access to the treatment consideredmost likely to be helpful.

In the present study, only a minority of partici-pants (39.6) considered the ‘main problem’ of theperson described in the vignette to be an eating dis-order, and few participants (14.5%) identified theproblem as BN. These findings are concerning giventhat the vignette was unambiguous in its reference tothe characteristic features of BN, namely, binge-eating, self-induced vomiting and laxative misuse.The perception that BN is primarily a problem of lowself-esteem, which is consistent with findings fromstudies of both AN and BED, may be one of thereasons that evidence-based treatment is so uncom-mon among individuals with BN and related disor-ders.12,16 Of note in this regard is that participantsidentified as probable eating disorder cases tendedto be more likely to consider Kelly’s main problem tobe low self-esteem (65.4% vs. 46.5%), and less likelyto consider Kelly’s main problem to be an eatingdisorder (34.6% vs. 53.5%), than participants who didnot have a high level of eating disorder symptoms.

Also concerning is the finding that less than onethird of participants (29.0%) identified as probableeating disorder cases believed that they currentlyhad a problem with their eating. Some caution isneeded in interpreting this finding, as responses tothe question addressing self-recognition of aneating problem are likely to depend, at least in part,on the extent to which participants’ own behavioursmatched those described in the vignette.34 However,poor eating disorders MHL may also be a factor.Although AN has received considerable attention inthe popular media in Singapore and other Asiancountries in recent years, bulimic eating disordershave received comparatively little attention, andknowledge of the nature and treatment of these dis-orders may be poor among both individuals affectedand primary care practitioners.35 Of note in thisregard is that an eating disorders module of theMental Health First Aid (MHFA) guidelines has

recently been published.36 The MHFA programme,developed by Jorm and colleagues in Australia, hasoperated in Singapore since 2006.37 We are not awareof any other prevention or early intervention pro-grammes for eating disorders in Singapore, nor ofany attempt to evaluate the benefits of the MHFA inthe Singaporean population.

Consistent with findings from previous studies ofMHL relating to eating disorders and other mentalhealth problems,13,15,16 participants in the presentstudy were less positive about the benefits of psy-chiatrists than other health professionals. In fact, inthe present study, psychiatrists were ranked belowfamily members and friends in terms of perceivedhelpfulness. One possible interpretation of thesefindings is that psychiatrists are more closely asso-ciated with those aspects of treatment about whichthe public is most ambivalent, namely, inpatienttreatment and the use of psychotropic medication.Hence, there may be a need for information to theeffect that inpatient treatment and the use of psy-chotropic medication may be helpful for individualswith eating disorders in some cases. Participants’ambivalence about the prospects of full recovery,given treatment, is more difficult to interpret, giventhat specific psychotherapy is not always effective inthe treatment of BN and related disorders, and giventhat relapse is not uncommon.24,38

The present findings suggest that dealing withpersonal problems within one’s social circle maybe common in Singapore, perhaps reflecting theimportance traditionally attached to the family unitin Asian cultures and the reluctance to have per-sonal information aired outside of this unit.17 Thefindings also underscore the importance of healthpromotion programmes for eating disorders thattarget not only individuals at risk, but also thosewith whom they are likely to interact.39,40 The role ofthe young women’s mothers may be particularlyimportant in this regard, as many participantsreported that they would approach their mothersfirst were they to have a problem such as the onedescribed. However, participants with a high level ofeating disorder symptoms were less likely to rate‘talking about the problem with a friend or familymember’ as helpful than those who did not. Hence,even in a culture where a reliance on family andclose friends is highly regarded, denial and secrecyassociated with bulimic behaviours may neverthe-less hinder early intervention.

The strong preference for consultation withfemale, rather than male, family members andfriends is also of interest, and may reflect a percep-tion that males are less likely to be sympathetictowards sufferers.26 Regrettably, the beliefs and



attitudes of males concerning the nature and treat-ment of eating-disordered behaviour, thus far, havebeen largely ignored by researchers.41 Hence, this isan important direction for future research. We chosenot to include males in the present study becausethis was the first study of eating disorders MHL in anAsian country, and we wanted to be able to comparethe findings with previous research in Australianwomen.

The primary limitation of the present study wasthat the assessment comprised a small number offorced-choice questions that addressed only oneaspect of eating disorders MHL, namely, beliefsabout treatment and treatment seeking for BN. Inaddition, as this was a cross-sectional study, anyinferences about the direction of associationsbetween variables are speculative. Findings relatingto the prevalence of probable eating disorder casesand associations between eating disorder psycho-pathology and responses to specific questionsshould also be interpreted with caution, given thatprobable cases were identified on the basis of self-reported eating disorder features.31

Finally, it should be noted that evidence for a rela-tionship between individuals’ beliefs and attitudesrelating to mental disorders and actual treatmentseeking is, to date, limited, and the comparativeimportance of MHL variables and other potentialbarriers to treatment is unclear.42 It has been sug-gested that the influence of individuals’ beliefs andattitudes on help-seeking behaviour may be mostpronounced among individuals who experiencemarked impairment in role functioning associatedwith a mental health problem but who neverthelessdo not consult a health professional.42 However,evidence to support this hypothesis is lacking.

To conclude, aspects of the eating disorders MHLof young Singaporean women may be conducive tolow or inappropriate treatment seeking. The find-ings, which are consistent with those of researchconducted in Australia and other Western nations,suggest that health promotion programmes may beneeded to improve eating disorders MHL in newlyindustrialized Asian countries, and that these pro-grammes need to target not only at-risk individuals,but also their family members and social circle.

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APPENDIX I

Vignette used in the mental healthliteracy survey

Kelly is a 20-year-old second-year arts student inuniversity. Although slightly overweight as an ado-lescent, Kelly’s current weight is below average forher age and height. However, she thinks she is over-weight. Upon starting university, Kelly joined afitness programme at the gym and also startedrunning regularly. Through this effort she graduallybegan to lose weight. Kelly then started to ‘diet’,avoiding all fatty foods, not eating between meals,and trying to eat set portions of ‘healthy foods’,mainly fruits and vegetables and bread or rice, eachday. Kelly also continued with the exercise pro-gramme, losing several more kilograms. However,she has found it difficult to maintain the weight loss,and for the past 18 months her weight has beencontinually fluctuating, sometimes by as much as5 kg within a few weeks. Kelly has also found it dif-ficult to control her eating. Although able to restricther dietary intake during the day, at night she isoften unable to stop eating, bingeing on, forexample, a loaf of bread and several pieces of fruit.To counteract the effects of this bingeing, Kelly takeslaxative tablets. On other occasions, she vomits afterovereating. Because of her strict routines of eatingand exercising, Kelly has become socially isolated.



Documents

Eating disorders mental health literacy in Singapore: beliefs of young adult women concerning treatment and outcome of bulimia nervosa