Hearing voices in the eating disorders field: Embracing qualitative research
By Kelly Ann Zainal, Research Coordinator, Singapore General Hospital
Eating disorders (ED) have often been
misunderstood, glamorised, contested over, and
are a source of loss and confusion to many.
Despite their widespread impact on patients,
caregivers, clinicians, researchers and the general
public, many would probably agree that very little is
known about ED, especially in the Asian context.
Although coverage of ED may have increased in
local and international mass media, methodical
research in the ED field in Singapore is still
relatively scarce compared to that in the West.
In this article, I would like to make a case for the use of qualitative research in relatively littleknown disorders or conditions, such as ED, in order to better understand the meaning and
experiences ascribed by affected individuals and groups – in essence giving them a voice.
This could in turn lead to optimisation of prevention, diagnostic and treatment efforts.
The number of persons diagnosed with ED has been steadily increasing in the Singaporean
population each year, especially among the younger age groups 1–3. This group of disorders includes
anorexia nervosa (characterised by restrictive eating, sometimes coupled with excessive exercise),
bulimia nervosa (in which patients typically present with binge-purge cycles), binge-eating disorder,
avoidant-restrictive food intake disorder, and a few others. Some initial ED research in the Singapore
context revealed that:
(1)
(2)
(3)
(4)
In patients diagnosed with ED, symptomatic presentations and body image dissatisfaction are
2–4
similar to those in the West .
1
7.4% of young females are at risk of developing an eating disorder .
Limited mental health literacy in young Singaporean women towards bulimia nervosa may
5
contribute towards low or inappropriate treatment-seeking behaviour .
In Singaporean healthy controls, body image dissatisfaction may be higher than their Australian
4
counterparts .
The complex effects of cultural and regional specific factors on the prevalence, diagnosis and
treatment of ED make it pertinent to study these disorders in our local context, despite the presence
of extensive literature internationally.
Some research questions to consider locally could include:
•
•
•
•
How prevalent are EDs in Singapore?
What affects individuals from seeking treatment and what may prompt them to seek treatment?
How differently might eating disorder symptoms be presented in Singapore?
How do parents cope with caring for their children with EDs?
•
•
•
What kind of challenges do parents face? How can clinicians, therapist and the healthcare
system better support them?
How do medical and allied health professionals perceive EDs and how proficient are they in
detecting, diagnosing and treating patients?
How does the general public view EDs and those suffering from them?
These questions could be more appropriately tackled by qualitative research methods – using indepth interviews, surveys and ethnographic studies to explore the salient issues voiced out by the
relevant target groups for each research question.
My experience with qualitative research in psychiatry has been eye-opening and inspiring. The first
taste of it was during my post-undergraduate internship at King’s College London’s Eating Disorders
6
Research Group. The study has since been published in the Journal of Eating Disorders . At that
time, the team was in the midst of a two-year long randomised controlled trial comparing two
treatments for adult outpatients with anorexia nervosa (for more information regarding the trial, refer
7
to Schmidt et al. ) In that study, we used both quantitative and qualitative methods to develop a more
wholesome picture of patients’ experiences during their treatment; treatment acceptability and
credibility ratings were obtained from the participants, followed by written feedback regarding their
experience in the treatment. They were then assigned to one of two treatment methods – either the
Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA) or Specialist Supportive
Clinical Management (SSCM). Quantitative and qualitative data complemented each other in
supporting MANTRA treatment plan as being more acceptable, credible and the one that garnered
most positive feedback from patients. Even though the trial eventually found that clinical variables
improve in both groups compared to baseline, with no significant difference between the two groups
8
of patients , knowing which treatment and its specific components patients preferred could have an
impact on drop-out rates and follow-up outcomes in the clinical setting.
Despite the lack of any published qualitative study in ED locally, the outlook appears positive with
several ideas currently in discussion. Given the boundless potential of qualitative research methods in
exploring clinically relevant questions, I hope that it will be adopted more in the budding clinical
research ecosystem in Singapore. We could give patients, caregivers, clinicians, researchers and the
general public the voices that they deserve.
About the Author
Kelly Ann Zainal graduated with a Bachelor of Social Sciences
(Honours) in Psychology from the National University of Singapore.
Her research interests include various aspects of clinical psychology,
particularly eating disorders, and qualitative methods. Currently, she
is a Research Coordinator at the Eating Disorders Programme
(EDP) at Singapore General Hospital. Her responsibilities include
maintaining the team’s databases, as well as research-related issues
such as ethics application, recruitment of participants, data entry and analysis, and writing of
manuscripts. She is currently involved in several active research projects in EDP.
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References
1.
Ho TF, Tai BC, Lee EL, Cheng S, Liow PH. Prevalence and profile of females at risk of eating
disorders in Singapore. Singapore Med J. 2006;47(6):499-503.
2.
Lee HY, Lee EL, Pathy P, Chan YH. Anorexia nervosa in Singapore: An eight-year
retrospective study. Singapore Med J. 2005;46(6):275-281.
3.
Kuek A, Utpala R, Lee HY. The clinical profile of patients with anorexia nervosa in Singapore:
a follow-up descriptive study. Singapore Med J. 2015;56(6):324-328. doi:10.11622/smedj.2015090.
4.
Soh NL, Touyz S, Dobbins TA, et al. Restraint and eating concern in North European and
East asian women with and without eating disorders in Australia and Singapore. Aust N Z J
Psychiatry. 2007;41:536-545.
5.
Chen A, Mond JM, Kumar R. Eating disorders mental health literacy in Singapore: Beliefs of
young adult women concerning treatment and outcome of bulimia nervosa. Early Interv Psychiatry.
2010. doi:10.1111/j.1751-7893.2009.00156.x.
6.
Zainal KA, Renwick B, Keyes A, et al. Process evaluation of the MOSAIC trial: treatment
experience of two psychological therapies for out-patient treatment of Anorexia Nervosa. J Eat Disord.
2016;4(2). doi:10.1002/erv.2278.
7.
Schmidt U, Renwick B, Lose A, et al. The MOSAIC study - comparison of the Maudsley
Model of Treatment for Adults with Anorexia Nervosa (MANTRA) with Specialist Supportive Clinical
Management (SSCM) in outpatients with anorexia nervosa or eating disorder not otherwise specified,
anorexia nerv. Trials. 2013;14(1):160. doi:10.1186/1745-6215-14-160.
8.
Schmidt U, Magill N, Renwick B, et al. The Maudsley Outpatient Study of Treatments for
Anorexia Nervosa and Related Conditions (MOSAIC): Comparison of the Maudsley Model of
Anorexia Nervosa Treatment for Adults (MANTRA) with specialist supportive clinical management
(SSCM) in outpatients with. J Consult Clin Psychol. 2015;83(4):796-807. doi:10.1037/ccp0000019.