Main findings and comparison with the existing literature

In this study we investigated patterns of stigmatising beliefs towards people with eating disorders, depression and alcohol dependence, how these have changed over 10 years (1998–2008), and how they are associated with sociodemographic factors.

In both 1998 and 2008, respondents thought that people with eating disorders were to be blamed for their conditions more than people with depression, but not more than those with alcohol dependence. Participants also believed that it would be easier to recover from an eating disorder or improve if given treatment, than it would be to recover from either depression or alcohol dependence. These results possibly reflect the widespread belief that eating disorders are under one's control and could be easily recovered from, as previously reported.^{Reference Mond, Robertson-Smith and Vetere7,Reference Ebneter and Latner8}

However, we also found that, over the 10-year period studied (1998–2008), these stigmatising views towards eating disorders decreased across the board, which was contrary to our hypothesis. This had not been the case when the 1998 results were compared with the results of the 2003 survey (as these only reported improvement on the two ‘recovery’ questions)^{Reference Crisp, Gelder, Goddard and Meltzer10} and was not observed to the same extent for the other two comparator conditions. This trend is encouraging and is in line with global literature showing improvements in stigma towards mental health diagnoses. Nevertheless, to date this research has primarily focused on depression and schizophrenia and largely overlooked eating disorders, hence comparisons of our findings with those of other countries is difficult.^{Reference Angermeyer, Matschinger and Schomerus14}

Finally, we observed that stigmatising views towards people with eating disorders were more common among certain groups, which was broadly in line with our hypothesis. Males, participants who were older or from minority ethnic backgrounds, and those with lower levels of formal education were more likely to attribute blame to people with eating disorders; this pattern was also observed across the other conditions. Older participants were more likely to think that people with eating disorders, as well as other conditions, will never recover fully even if given treatment. On the other hand, compared with women, men were more likely to believe that it was possible to recover from eating disorders and alcohol dependence, but their views did not differ from those of women when considering depression. Previous studies using 1998 and 2003 ONS data found largely similar patterns, although these did not disaggregate between different stigma domains and did not mutually control for sociodemographic factors.^{Reference Crisp, Gelder, Goddard and Meltzer10,Reference Crisp, Gelder, Rix, Meltzer and Rowlands11} Our study therefore offers a more granular understanding of the relationship between different sociodemographic characteristics and specific stigma domains.

Strengths, limitations and direction for future research

This study has a number of strengths. We used nationally representative general population data spanning a decade, thus avoiding selection biases associated with the use of convenience samples (for example college students). We compared eating disorders with two conditions that are often comorbid with eating disorders and share similar epidemiological profiles (depression) and that we hypothesise would have similar stigma profiles (alcohol dependence), as opposed to disorders that have different stigma and epidemiological profiles, for example dementia or schizophrenia.^{Reference Hudson, Hiripi, Pope and Kessler15} We measured our outcomes using continuous scores rather than dichotomising answers, allowing us to investigate our outcomes on a continuum of severity while also achieving good statistical power. Finally, this was the first study to investigate sociodemographic characteristics associated with individual stigma domains and using regression models to control for confounding, thus ensuring robustness of findings.

Despite these strengths, a number of limitations should also be acknowledged. One limitation, as with all large population-level surveys, is that there was some selective attrition that became more prominent in the most recent survey. Although we included predictors of attrition in our analyses, we cannot exclude the possibility that selection bias could have occurred if survey participation was conditional upon certain sociodemographic characteristics, for instance female gender or White ethnicity both of which appear to be over-represented compared with 2011 ONS census figures.¹⁶ We did not adjust regression models for multiple comparisons as, given some groups were small (for example ethnic minority participants), attempting to avoid a false positive would have increased the risk of false negatives. Instead, we interpreted the strength of the evidence based on effect size and 95% confidence intervals, and the majority of the associations observed had very small P-values, which suggests there was strong statistical evidence to support a difference.

The survey asked about ‘eating disorders’ without differentiating between bulimia nervosa, anorexia nervosa or binge eating disorder. As there is some evidence that these conditions may have different stigma profiles,^{Reference Griffiths, Mond, Murray and Touyz6,Reference Ebneter and Latner8} future studies should aim to include questions on individual eating disorders. The survey also asked about ‘severe depression’ as opposed to ‘depression’ but did not include any indications of severity for any of the other conditions, which may have biased participants’ responses if individuals, or specific sociodemographic groups, perceived this condition as being more severe than the others. The questions around ability to recover did not directly ask about respondents’ beliefs around severity of each condition under study and could have measured knowledge around availability of effective treatment options. The lower scores we observe on these questions could have therefore indexed better mental health literacy and fewer stigmatising beliefs. However, we propose that the latter is unlikely as we do observe marked differences between depression and eating disorders, for instance, despite the fact that evidence around effective treatments for eating disorders is weaker than that around effective treatments for depression. Hence, we believe these questions are likely to capture underlying beliefs around severity. Nevertheless, future surveys and studies should include more explicit questions around severity in order to tease apart these two important domains. They should also include questions on participants’ weight to explore how the latter might influence people's views on eating disorders.

Although few have addressed eating disorders specifically, in recent years there have been more public health campaigns to increase mental health literacy and decrease stigma,^{Reference Bullivant, Rhydderch, Griffiths, Mitchison and Mond5} also helped by public figures talking more openly about their mental health. Although some of the improvement in stigmatising beliefs that we observed could have been because of specific campaigns, our design could not test this, as participants were not asked whether they had been exposed to any specific campaign and, despite covering a 10-year time frame, the data is no longer current. It is therefore important that such surveys continue to be repeated and that evaluation of the effectiveness of anti-stigma and mental health literacy campaigns is embedded in their design in order to understand the impact of anti-stigma and awareness-raising campaigns on trends in mental health stigma. Finally, our results are specific to the UK and might not be generalisable to other countries. It is therefore important that data on mental health stigma is more widely collected so that cross-country comparisons can be conducted.

Implications of our findings

The finding that males and ethnic minority participants held more stigmatising views towards people with eating disorders has important clinical and research implications. Eating disorders are often framed in the media as White women illnesses. Men who experience these conditions are portrayed as ‘atypical’ and ‘less of a man’.^{Reference MacLean, Sweeting, Walker, Patterson, Räisänen and Hunt17} These negative views could be responsible for the greater levels of stigmatising beliefs we observed in our study and greater internalised stigma seen in males with eating disorders compared with females, which have been reported by previous studies.^{Reference Griffiths, Mond, Murray and Touyz6} However, we found that males had more stigmatising views towards depression and alcohol dependence as well, and this has also been previously observed.^{Reference Oliffe, Ogrodniczuk, Gordon, Creighton, Kelly and Black18} Feelings of shame around experiences of mental illness in males have been shown to hinder help-seeking behaviours^{Reference Griffiths, Mond, Li, Gunatilake, Murray and Sheffield19} and are thought to be one of the reasons behind their increased risk of suicide.^{Reference Rasmussen, Hjelmeland and Dieserud20}

General population studies suggest that the prevalence of eating disorders and disordered eating in the UK population does not differ across ethnic groups.^{Reference Solmi, Hatch, Hotopf, Treasure and Micali2} However, there is evidence that individuals from Black and Asian minority backgrounds are systematically under-represented in eating disorder services.^{Reference Abbas, Damani, Malik, Button, Aldridge and Palmer21} This could be explained by lower rates of help-seeking, failure to identify eating disorders in these populations in primary care, or both. Qualitative studies have highlighted that lower mental health literacy and greater stigma towards mental health conditions are barriers towards help-seeking for eating disorders^{Reference Wales, Brewin, Raghavan and Arcelus22} and mental health problems in general in minority ethnic communities.^{Reference Memon, Taylor, Mohebati, Sundin, Cooper and Scanlon23} Interventions aimed at increasing mental health literacy could therefore have multiple benefits – from encouraging greater help-seeking to reducing internalised stigma and improving people's quality of life. For instance, a recent systematic review found that interventions that focused on biological explanations of eating disorders, as opposed to sociocultural ones, were more successful at reducing stigma towards these conditions.^{Reference Doley, Hart, Stukas, Petrovic, Bouguettaya and Paxton24} However, the same review also cautioned against excessive reliance on biological explanations as these might give rise to deterministic beliefs around the difficulty of recovering from or preventing an eating disorder.^{Reference Doley, Hart, Stukas, Petrovic, Bouguettaya and Paxton24} Our study suggests that, increasing public understanding that eating disorders also affect males and people from ethnic minority backgrounds as part of anti-stigma campaigns could help de-stigmatise them in these groups. It is therefore important that public health campaigns aimed at improving mental health literacy are inclusive and target diverse groups.

In conclusion, we found that although stigmatising views towards eating disorders had improved in 2008 compared with the late 1990s, core differences vis-à-vis other conditions, remained. Although new surveys presenting more current data are needed, our study still provides useful insights on which aspects of eating disorder mental health literacy might need to be addressed by future anti-stigma and mental health literacy campaigns, and which groups might benefit from the latter. Such interventions should be considered a key priority alongside other public health strategies as they are likely to promote greater help-seeking behaviours, improve individuals’ well-being and lead to greater investment in research and clinical services, ultimately leading to improved prognosis and opportunities for prevention.