The aim of the current study was to examine whether a training intervention on mental health first aid for eating disorders was effective in changing knowledge, attitudes and behaviours towards people with eating disorders. Results suggest that the training intervention was associated with significant improvements in knowledge, which were maintained over time. There was no evidence to suggest the training program produced sustained changes in attitudes towards individuals with eating disorders, though these were relatively empathic at baseline. There was also little quantitative evidence to suggest the training program produced significant changes in behaviours towards individuals with eating disorders, however, qualitative responses in the small sample who did have contact with an individual with an eating disorder, suggested the training was associated with changes in first aid behaviours.
Changes in knowledge
There was no significant change in the knowledge of eating disorder symptoms across time. It is possible that this finding is the result of participants lodging less detailed or less specific answers across time, as the follow-up questionnaire was sent to the majority of participants between October and November; a busy exam period and the end of the academic year. It is also possible that the training failed to produce a significant increase in knowledge scores over time because there was not enough emphasis placed on eating disorder specific signs and symptoms throughout the curriculum. In fact, the training emphasises the importance of recognising the development of non-specific signs of distress, as this is the best opportunity to provide timely mental health first aid. As such, participants were taught to look for a change in “a person’s thinking, emotional state and behaviour, which disrupts the ability to work or carry out other daily activities and engage in satisfying personal relationships” , which is how the MHFA program defines the onset of a mental health problem. Future evaluations may therefore benefit from an item designed to measure a change in knowledge regarding the most appropriate time to provide mental health first aid, rather than specific knowledge relating to the wide range of eating disorder signs and symptoms.
Unlike knowledge of signs and symptoms, accurate recognition of the problem in the MHLQ-B vignette, as ‘bulimia nervosa’, increased significantly immediately after the training. Furthermore, recognition of the problem as any eating disorder also increased, and this change was sustained over time. Importantly, this effect of increased recognition, was not generalised to any mental health problem; participants were not more likely to label the problem in the vignette with general terms relating to mental ill-health at follow-up, indicating that the improved recognition was specific to eating disorders, and in particular to bulimia. It is interesting that participants’ increased recognition of the problem as any eating disorder was more robust than the specific recognition of the problem as bulimia. Given that the training encourages participants to look for changes in eating and exercise behaviours that are interfering with function, rather than encouraging participants to look for indicators of diagnostic categories, this result is perhaps more desirable than having a sustained increase in the specific recognition of the problem as bulimia.
The Knowledge of effective treatments and professionals scale in the MHLQ-B showed that participants’ knowledge of effective treatments for eating disorders also significantly improved over time. Unfortunately this was not true for the Knowledge of informal help-seeking scale. While it was found that total scale scores significantly improved after the training, these improvements were not maintained at follow-up. This result, however, is perhaps not unexpected. While the treatment literature recognises the importance of friends and family in the help-seeking and recovery process, it is also apparent that the social network can have a negative influence on the development of mental illness and barriers to care [72, 73]. It is therefore true that the effectiveness of individuals in facilitating help-seeking and recovery will depend on their level of knowledge, skill and empathy. As this concept was discussed as part of the training, it is perhaps not a surprise that ‘helpful’ ratings did not change across time. It is also important to acknowledge that this study is the first time the Knowledge of informal help-seeking scale had been implemented. Given its construction from just 4-items, further testing of its psychometric properties would further elucidate its utility in future evaluations of MHFA training. Furthermore, future evaluations may benefit from an examination of changes to inappropriate informal help-seeking, rather than a narrow focus on changes in the small number of appropriate strategies.
The FAKT showed that participant knowledge of first aid skills improved significantly after the training and, despite a drop-off in the follow-up period, this improvement was maintained at follow-up, indicating that the training was associated with a gain in knowledge that was sustained over time. As this is the first time the FAKT instrument has been implemented, the psychometric properties are not well known. It is therefore possible that increases from baseline to post-training were the result of re-test effects. However, given that there was a small drop in knowledge from post-training to follow-up, it appears that each re-testing event does not necessarily result in ongoing improvement over time.
Responses to the Mental Health First Aid item, which asked participants how they would help ‘someone like Kelly’, indicated that the training was associated with a significant increase in knowledge of the appropriate actions a person should take when providing a first aid intervention, as outlined by the MHFA action plan. However, this change was not sustained over time. There are two possible explanations for this result. One is that, given the open-ended response format for this item, participants provided less detailed responses at follow-up, due to their academic time constraints, and hence scored more poorly than at post-training. Another plausible explanation is that the training was insufficient in duration to produce a lasting effect. It is perhaps not unsurprising that participants could not remember these five specific actions, six months after receiving a 4-hour intervention. Furthermore, given that a previous evaluation of the full MHFA training program found an increase in knowledge of the action plan, which was maintained at six month follow-up , it is likely that had the current training involved more time to discuss and role-play the action plan, retention of information would have been maintained over time.
Overall, results for the items assessing knowledge showed that the training was associated with an immediate and lasting improvement in eating disorder problem recognition, knowledge of effective treatments, and consensus-based first aid strategies. Although results showed that there were increases in knowledge for informal help-seeking strategies and the MHFA action plan, these changes were not maintained over time, perhaps indicating that the intervention was too brief to produce lasting effects. These results do however provide preliminary support for the impact MHFA training can have on mental health literacy for eating disorders.
Changes in attitudes
Scores on the Social Distance Scale remained unchanged after the training and during the follow-up period, compared to baseline. Interestingly, in a review performed by Jorm and Oh , interventions aimed at reducing stigmatising attitudes of similar length to the current training, were found to have similar results whereby no significant changes in the total score were found over time. It therefore appears that the current intervention may have been too short and required more direct contact with people affected by eating disorders, to achieve the desired reduction in social distance.
The MHLQ-B item assessing participant ratings of how distressing they believed Kelly’s problem would be, found that there were no significant differences associated with the training, despite some small fluctuations in ratings. Two plausible explanations for this result can been considered. First, it is possible that there was an insufficient ‘dosing’ effect, whereby the intervention was too short to provide lasting effects over time. If this were true, a longer intervention or booster session should produce the desired result. The second possibility is that participants were at ceiling when first measured at baseline. Given the high proportion of participants who rated Kelly’s problem as either ‘very’ or ‘extremely’ distressing, it is possible that the intervention was unable to produce any further increase. As a point of comparison, a community-based survey of adolescent girls’ mental health literacy for eating disorders found that most respondents believed that it would be ‘very’ (40.0%) or ‘extremely’ distressing (45.0%) to have a problem like Kelly’s, indicating that there was little need for an intervention to educate participants about the distressing nature of the condition .
The desirability of bulimic symptoms was also assessed with a MHLQ-B item, which found that the majority of participants reported that they had ‘never’ or ‘rarely’ thought that ‘it might not be too bad to be like Kelly given that she has been able to lose a lot of weight’. This finding is in contrast to previous evaluations of MHLQ-B, which have found much higher levels of desirability. The current finding may be an artefact of older adults and male participants being included in the sample, rather than a non-representative sample per se. That the desirability ratings remained stable over time and showed no significant change after the training, can be explained in two ways. First it is possible that the training had no effect on how desirable participants found bulimic symptoms. However, it is also possible that there was a ceiling effect. Given that it is expected the intervention would have the strongest effect among participants who considered bulimia desirable, though most did not indicate any desirability for bulimic symptoms at baseline, the beliefs of the current sample left little room for improvement.
Taken together, items assessing attitudes towards bulimia indicate that the sample at baseline were already empathic. It is therefore difficult to infer from these results whether the intervention was effective in changing attitudes about eating disorders. Although a sample with less empathic attitudes at baseline may have shown a statistically significant improvement after training, it remains a welcome finding that members of the community already express empathic attitudes towards individuals with eating disorders.
Changes in behaviour
The amount of contact participants had with individuals with eating disorders was measured using the Level of Contact Report and two Mental Health First Aid questions. Across all measures, there were no significant differences found between the amount of contact with individuals with eating disorders before the training and the amount of contact after the training. One possible explanation for this finding is that the environment in which the participants studied, worked and resided, was not amenable to producing a change in the amount of contact a participant may experience. For example, the large majority of students and staff undertake residence at a college for an academic year, beginning at the start of March and ending in late November. Between these months, there is very little change in the composition of staff or students in the residences. In the current study, the baseline measurement, training and follow-up period all fell within the 2010 academic year. Furthermore, because college residences are an environment where individuals live in very close contact with one another, and the welfare of students is closely monitored by pastoral care teams, it is possible that the majority of individuals with eating disorders, who were present within the residences, were already identified at baseline and this number could not be significantly improved upon after the training and during the follow-up period. Another possible explanation for the non-significant change in contact is that the training intervention had no effect on participant behaviour toward those with eating disorders. However, given that there was a significant increase in the ability to accurately recognise an eating disorder, that knowledge of effective first aid strategies significantly increased, and there was no increase in social distance, it appears unlikely that the intervention would not influence contact to some degree. A second and longer follow-up period, crossing over more than one academic year, may elucidate any effect of the college environment on the level of contact found among participants. However, it should be noted that some previous evaluations of MHFA training have also recorded no change in the level of contact with those with mental illness [50, 54].
The third Mental Health First Aid item was designed to measure change in the amount of help provided to those with eating disorders. No significant increase was found after the training. Some previous MHFA training evaluations have also failed to find an increase in amount of help provided. Of the four studies that have used the same method of evaluating help provided, two studies found no significant differences between baseline and follow-up [56, 76].
The current study also found no change in the type of help provided by participants. Given the relatively small number of participants who reported providing first aid, it is possible that there was inadequate power to detect an effect. This postulate is supported by the finding that the majority of participants who provided first aid reported that they had done things differently to before they received the training, according to responses on the First Aid Experiences Questionnaire. Furthermore, the training was associated with a significant increase in participant confidence in providing first aid. In combination then, these results suggest that if a second and longer follow-up testing period was employed, which would allow participants more time to be in contact with and provide assistance to individuals with eating disorders, the existence of any significant changes in behaviour after the training, would be clarified.
Responses to the First Aid Experiences Questionnaire were largely positive, as many indicated that the training allowed them to feel more knowledgeable, confident and better prepared to recognise and provide assistance to someone developing or experiencing an eating disorder. Although the quantitative measures found no statistically significant increases in the amount of help provided, the open-ended information gathered by this instrument suggests that participants approached someone they were concerned about with more empathy and patience than before, and that this change was a result of the training. Furthermore, the majority of those who had not provided first aid indicated that the training had impacted on the way they viewed eating disorders as mental illnesses worthy of care, understanding and effective treatment. Interestingly, it appeared that the training generalised to assisting individuals with other mental health problems, as an equal proportion of participants reported providing first aid to individuals with mental illnesses other than eating disorders.
Participants who had provided first aid reported feeling reasonably successful in their intervention, however, many went on to explain that the unresolved nature of the person’s illness contributed to their sense that their intervention was not a complete success. Given that this finding reiterates that of the earlier evaluation of guidelines being downloaded from the internet , future MHFA training would do well to include a discussion of what ‘successful’ first aid might look like and how participants should not expect immediate or necessarily complete recovery, as a result of providing assistance and facilitating appropriate treatment seeking. Interestingly, a much larger proportion of participants who reported assisting someone with another mental health problem reported feeling that their first aid intervention was successful. The ambivalence about success may therefore be particular to assisting in the case of an eating disorder.
Importantly, the First Aid Experiences Questionnaire provided no reports of adverse experiences associated with an attempted first aid intervention. Conversely, participants indicated that as a result of their suggestion and assistance, seven individuals had sought help for their suspected eating disorder, and an additional three were better supported whilst already receiving care. Furthermore, three participants mentioned assessing for suicide risk where they wouldn’t have done so before the training. While statistical inferences from these data are not possible, it is encouraging that these responses indicate the training was associated with a higher level of effective assistance, and ultimately, more appropriate help-seeking.
In sum, the findings from instruments measuring behavior change suggest that there is some limited evidence for a change in first aid behaviours and an increase in appropriate help-seeking, albeit among a small number of participants. Many of the findings in the current research confer with those of previous MHFA evaluations employing a six month follow-up period, which suggests that a second and longer follow-up period, for example at 12 months after training, might allow for an increase in the size of the sample providing assistance, and thereby an increase in the power to detect any statistically significant effect of the training on behaviour change.
Changes in mental health
The EDE-Q and K10 were implemented to assess any changes in the mental health of participants. Given previous research evaluating preventive interventions for eating disorders has found that providing information about eating disorder symptoms can lead to an increase in eating pathology, the EDE-Q was used in the current study to assess for any negative impact on participants. Despite being normative at baseline, the sample’s average global EDE-Q score was found to be significantly lower at follow-up. There are two possible explanations for this outcome. The first is that the intervention had a positive effect on eating pathology. The second is that the result is due to a re-test effect, whereby scores improved (decreased) with each testing occasion, as has been shown to be possible with psychiatric instruments designed to assess negative self-characteristics . Without the presence of a control group to assess whether there is an inherent decrease in scores on the EDE-Q across time, it is not possible to conclude which of the two explanations is the more plausible. In any case, the current findings suggest no evidence that the training had a negative impact on the eating pathology of participants.
Although there was a slight decrease in K10 total scores from baseline to follow-up, this was not statistically significant. This finding is in accordance with previous evaluations of MHFA training and other mental health literacy interventions, and suggests that the training does not have a negative impact on the psychological distress of participants.
The absence of a control group is the primary limitation of this research. Without being able to control for extraneous variability in scores over time, concrete conclusions about the role of the training in causing improvements on a number of measures, such as the FAKT and EDE-Q, cannot be reached. However, given that the current research was designed to be a preliminary exploration of how the concept of mental health first aid might be applied to eating disorders, this study has produced some initial evidence to suggest that providing a training intervention to community members increases knowledge and confidence in providing first aid, as well as important data about how future evaluations could be best implemented.
A second limitation of this research is the composition of the sample at baseline. Prior to training, the majority of participants upheld empathic attitudes towards people with bulimia, had relatively good mental health literacy, a large proportion were already in contact with an individual with an eating disorder and had provided some level of assistance. In contrast to the community studies completed by Mond and colleagues, it appears as though the current sample were already functioning above average on a number of variables [e.g. [46, 49, 75, 78]. It was perhaps the nature of the residential college environment, where students live in close contact with one another, members of staff are highly trained in providing pastoral care, and all are well educated, which resulted in participants scoring relatively highly on most measures at baseline. It is also possible that because recruitment materials contained information about both eating disorders and mental health first aid, participants with favourable baseline scores enroled in this study. Research that had a much longer time frame for recruiting participants and could engage interested parties in more subtle ways, may have resulted in a different sample composition.
A third limitation of this research is the size of the sample who reported providing a first aid intervention. Although the proportion of participants who reported providing some form of help (n = 31, 42%) was similar to previous evaluations of MHFA training [e.g. , the power to uncover a statistically significant effect is limited by such small numbers. Importantly, the only investigation to examine first aid experiences in a follow-up period longer than six months, found that 78% of respondents had experienced a situation in which they had provided some help, 19 to 21 months after receiving the training . To ensure sufficient statistical power in future research evaluating MHFA training, a combination of a larger number of trained participants and a longer follow-up period should be employed.
Implications of this research
Across most measures of knowledge, significant improvements were found from baseline to post-training. However, these changes were often not maintained at follow-up, as sharp declines occurred in the follow-up period. That the current research was not able to find sustained effects for a number of instruments suggests that the duration or ‘dosing’ effect of the training was inadequate. Given that evaluations of the full MHFA training program, which is presented across four sessions and totals 12 hours, has found much stronger effects at six month follow-up, it would be beneficial for the field of eating disorders for future research to investigate the effect of providing the current training within the full MHFA syllabus. It is also possible that presenting the current training over two or three sessions, with the inclusion of more material focused on the reduction of stigmatising attitudes and modeling of first aid behaviours, would produce lasting significant changes to knowledge, attitudes and behaviours. Such change would no doubt be important in encouraging those with eating disorders to seek appropriate help early, and thereby reduce the current heavy burden associated with these illnesses.