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Exploring validated strategies for screening for eating disorders in adolescents and adults in primary health care: a scoping review protocol

Systematic Reviews volume 13, Article number: 288 (2024) Cite this article

Abstract

Background

This study will be the first scoping review dedicated to investigating screening strategies for eating disorders specifically performed in the primary health care setting, as no comprehensive examination has been performed to date. Our primary aim is to explore the available literature and assess and identify validated screening strategies for eating disorders in adolescents and adults within the primary care context.

Methods

The study protocol was developed following the guidance outlined by the Preferred Reporting Items for Systematic reviews and Meta-Analyses Protocols and the Joanna Briggs Institute methodology for scoping reviews. This study will adhere to the PRISMA extension for scoping reviews to report review data. The protocol was registered on the Open Science Framework. The review will include studies that involve validated screening strategies for eating disorders in adolescents and adults utilising primary health care services. Experimental, quasiexperimental, observational, qualitative, and mixed-methods study designs and reviews will be eligible without language or publication year restrictions. Six databases (MEDLINE-PubMed, Embase, LILACS, CINAHL, Web of Science, PsycINFO) and grey literature will be searched. Studies will be selected and extracted by two independent reviewers via online Covidence. The results will be presented in narrative form and through tables and graphs. When possible, descriptive qualitative content analysis will be conducted.

Discussion

The expected results of this scoping review will shed light on validated strategies for screening for eating disorders in primary health care. This will equip health care professionals with well-substantiated empirical evidence. Moreover, it is anticipated to uncover research gaps, nurturing the ongoing development and refinement of screening strategies for eating disorders in primary health care. The results will be widely disseminated to the scientific community, policy-makers, service providers, and the general public.

Systematic review registration

This protocol has been registered on the Open Science Framework (https://osf.io/pybvf).

Peer Review reports

Background

Eating disorders (EDs) are psychiatric illnesses associated with severe distortions in eating and feeding behaviour, resulting in significant physical, social, and psychosocial impairments [1]. Evidence shows that EDs have multiple origins and are influenced by a complex interplay of biological, psychological, and sociocultural factors [2].

Despite underreporting, EDs affect a substantial proportion of the population, surpassing an estimated 55.5 million individuals worldwide and ranking 33rd among diseases with the most significant loss of years due to disability [3]. Anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) have emerged as the most globally recognised EDs and are more common in adolescent and young adult women [2]. The lifetime prevalence of AN is estimated to be 4% in women, in contrast to 0.3% in men, whereas BN affects 3% of women and 1% of men [4] and BED affects 1.4% of women and 0.4% of men [5]. Moreover, the average estimated time between symptom onset and the initiation of appropriate treatment is 29.9 months for AN patients, 53 months for BN patients, and 67 months for BED patients [6]. The longer the duration of the illness, the greater the risk of complications, disability, suicide attempts, and mortality [2, 7].

The delay and complexity of diagnosis are relevant factors in the treatment failure of EDs, emphasising the need for early intervention as a strategy to reduce the severe consequences associated with an ED [6, 8]. In the early stages, physical and laboratory examinations may not reveal abnormalities [9], whereas psychiatric interviews, which are typically used in clinics [10], may not be feasible in primary health care (PHC). Therefore, it is crucial to integrate ED risk screening into PHC [11,12,13], enabling referrals to specialised care services [14, 15] and facilitating early detection and effective treatment [6]. However, it is imperative to note that a robust system of specialised ED support must complement this strategy during treatment [16] to improve health outcomes for individuals undergoing screening.

Primary health care professionals often have little or no training in EDs, hindering the identification of these conditions and disordered eating behaviours for proper referral to specialised assistance [17]. Therefore, improving the knowledge of these professionals regarding ED behaviours and symptoms is essential to ensure adequate assessments at this level of care, ensuring that patients receive necessary support as early as possible [11, 18]. Additionally, the use of appropriate tools is necessary, ensuring simple, reliable, consistent, accurate, and culturally sensitive measurements for diverse populations and ensuring the quality and interpretability of the results [19]. However, the lack of practice and knowledge about comprehensive screening tools represents a significant barrier, resulting in the absence of screening even in high-risk groups, such as adolescents and women on restrictive diets, individuals with a high body mass index, and individuals with type 1 diabetes [12]. In this context, adopting adequately validated screening instruments and methodologies capable of identifying the risk of EDs in PHC is imperative for promoting and enhancing the provision of care and ensuring a more comprehensive and culturally sensitive health action for individuals undergoing evaluation.

Current research in the area

While there is a growing understanding of the importance of early identification of EDs and that screening instruments should be easy to apply and relevant in the context of PHC care, according to the pilot research of this scoping review protocol conducted on MEDLINE/PubMed, only a limited number of studies that aimed to investigate the use of these instruments and focus on methodologies to assist in the screening of EDs in this specific context were identified. It is essential to consider that, despite the availability of various validated instruments for examining ED risk behaviours, most of the identified studies predominantly focus on the use of just two scales: the Sick, Control, One Stone, Fat, and Food Questionnaire (SCOFF) and Eating Disorder Examination Questionnaire (EDE-Q). On the other hand, fewer studies explore methodologies that assist in recognising these behaviours [18, 20].

In the preliminary literature search, four systematic reviews [21,22,23,24], one rapid review [12], and one scoping review [25] covering various health care settings were identified, along with a meta-analysis of diagnostic accuracy testing in the PHC context [26]. Despite a recent scope review conducted by Kalindjian et al. [25], which focused on the early detection of EDs and explored the screening ED risk behaviours in several populations and health care settings, this review still needs to fully address our specific interests. The nature, extent, feasibility, and impact of using validated instruments and methodologies for ED screening among PHC users have yet to be exhaustively investigated. This lack of research directed at PHC emphasises the need for more comprehensive research in this setting. Thus, this research aimed to identify relevant studies that examined the entire process involving the application of validated instruments and methodologies for screening for EDs in PHC centres. Additionally, this review will include available studies that evaluate the perceptions of PHC professionals regarding the usefulness, applicability, and challenges associated with using these instruments. This inclusion provides a more comprehensive view of practical considerations and possible barriers and facilitators that can influence the successful implementation of these instruments.

Why is it important to do this review?

This protocol is part of an ongoing research project titled “Instruments and Screening Strategies for Eating Disorders among PHC users: A Scoping Review followed by a Systematic Review of Diagnostic Accuracy”, funded by the National Council for Scientific and Technological Development (CNPq) and the Department of Science and Technology of the Ministry of Health (Decit/SCTIE/MS). This scoping review on validated instruments and methodologies for ED screening among PHC users is crucial because it fills a considerable knowledge gap by focusing on the application of these instruments in PHC. Moreover, the results may identify the most appropriate and effective validated screening instruments in this context that can enhance care and improve patient health outcomes. This evidence-based review highlights gaps in the training of health professionals and contributes to the development of targeted programmes for the population, especially in a scenario where these problems are often underdiagnosed. Furthermore, the evidence can broaden the scope of ED research beyond the traditional clinical context, contributing to advancing knowledge and promoting mental health at a broader level.

Review questions

This review aims to explore the literature available on strategies (instruments and methodologies) for screening for EDs among PHC users. To achieve this objective, the elements of the PCC framework (participant, concept, and context) were applied to guide the main research question: “What is the existing evidence on validated strategies for screening for EDs in adolescents and adults in PHC?”.

Regarding evidence addressing the screening of EDs in adolescents and adults using PHCs as follows:

(Q1): What are the characteristics of validated strategies for ED screening and their application (who conducted the screening, when, how, where it was conducted, the frequency of use, and the duration of application) in the context of PHC?

(Q2): In which geographical, demographic, sociocultural, and economic contexts are validated screening strategies used?

(Q3): What evaluation methods have been used to determine the robustness of ED screening strategies?

(Q4): How can the feasibility of applying ED screening strategies in PHC be assessed, considering factors such as the proportion of patients accepting screening, their perceptions.

case identification, actions taken by the team, the barriers and facilitators encountered during implementation of the strategies, and the perceptions/experiences of professionals?

Methods

The scoping review (ScR) is an ideal approach for mapping the breadth of available evidence, providing comprehensive information on a specific topic and in specific contexts. Moreover, this methodology allows the identification of knowledge gaps [27]. This choice aligns with the objective of this research, justifying the use of a scoping review.

Since no specific guidelines are available for scoping review protocols, the guidelines established by the Preferred Reporting Items for Systematic reviews and Meta-Analyses Protocols (PRISMA-P; [28, 29]) were adopted (Additional file 1). This study follows the methodology recommended by the Joanna Briggs Institute (JBI) for scoping reviews [27], and the PRISMA extension for Scoping Reviews (PRISMA-ScR; [30]) will be used to report the results of this review. This protocol has been registered on the Open Science Framework (https://osf.io/pybvf).

Eligibility criteria for considering studies for this review

Table 1 illustrates the eligibility criteria according to the PCC framework of this proposed scoping review study. These criteria are supported by clearly articulated and well-defined concepts and terminologies. The key terms and definitions used in this review have been synthesised and presented in Table 2 to promote clarity and ensure consistency in interpreting the key concepts. Any validated self-report instrument used to investigate screening for EDs in adolescents and adults in primary health care (PHC) settings will be considered. These instruments include the Eating Attitudes Test (EAT), Eating Disorder Inventory (EDI), EDE-Q, Binge Eating Scale (BES), Binge Scale (BS), Bulimia Test (BULIT), Bulimic Investigatory Test, Edinburgh (BITE), Questionnaire on Eating and Weight Patterns (QEWP), SCOFF Questionnaire, Eating Disorder Screening for Primary Care (ESP-PC), and Eating Disorder Examination Questionnaire Short (EDE-QS). However, other instruments for screening for EDs may be considered if the study meets all the inclusion criteria for this review.

Table 1 PCC framework for defining the eligibility criteria of the studies
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Table 2 Key terms for this scoping review
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Information sources

A health librarian will assist with the search strategy, which will be conducted in three stages, as recommended by Peters et al. [27]. First, an initial limited search in MEDLINE (PubMed) will be performed to identify words contained in the title, abstract, and index terms used to describe articles on the topic. Controlled vocabularies Medical Subject Heading (MeSH) and Embase subject headings (Emtree) will also be used. Next, all identified keywords and terms will be used to develop a comprehensive search strategy for MEDLINE (PubMed, see Table 3). The definitive MEDLINE/PubMed search strategy was adapted as appropriate for each of the databases in this review. The search strategies for the other databases can be found in Additional file 2 [35]. Finally, a manual search of the reference lists of the included studies and consultation with area experts will be conducted to retrieve studies that meet the eligibility criteria but were not captured by the searches.

Table 3 Full search strategy in MEDLINE via PubMed
Full size table

The MEDLINE (PubMed), Embase (Elsevier), Latin American and Caribbean Health Sciences Literature (LILACS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and PsycINFO databases will be used for the electronic search. Supplementary searches in grey literature (ProQuest Dissertations and Theses Database and Google Scholar) will be conducted to expand the search and identify additional sources. There will be no language or publication year restrictions for this review.

Selection of evidence sources

After the search is completed on MEDLINE (PubMed), the citations will be imported into the Rayyan platform (https://www.rayyan.ai; [36]), where a pilot test will be conducted with two independent reviewers to increase accuracy in the selection process and calibrate the citation screening among the reviewers. For this purpose, 50 publications will be randomly selected for title and abstract reading, applying the preestablished eligibility criteria. The team will meet to discuss any discrepancies [37]. After this stage, the search strategy will be applied to each database, and the retrieved citations will be imported into the Covidence Veritas Health Innovation online software platform (www.covidence.org), to increase transparency and traceability during the review process. Duplicates will be removed [27,28,29].

Eligibility criteria will be applied during the title and abstract screening of all retrieved citations, and their relevance to the research question will be assessed. The eligibility of studies will be verified through full-text reading. To locate additional studies, the reference lists of all included studies will be examined, and expert responses will be checked. A citation containing insufficient information will be retained for eligibility verification in the full-text reading. After the full-text reading, the list and reasons for excluding studies that did not meet the inclusion criteria will be recorded and presented in a supplementary document. Two independent reviewers conducted the study selection process, which involved screening the titles and abstracts, as well as the full-text articles. Any inconsistencies in classification decisions will be documented, and the reasons will be discussed with a third reviewer. These steps will ensure a rigorous and transparent selection process.

Data extraction

Using the online software platform Covidence Veritas Health Innovation, Melbourne, Australia (www.covidence.org), data will be extracted (see Additional file 3) and mapped by two independent reviewers. To ensure clarity and consistency among reviewers, the data extraction will first be tested on a random sample of five studies by the reviewers. Then, the collection of information will begin, including specific details about the participants, concepts, context, study methods, types of analyses employed, screening strategies used, and key results for the research questions of this review. Any discrepancies will be resolved through discussion between the reviewers, and if necessary, a third reviewer may contribute. If necessary, the authors of the included evidence sources will be contacted to obtain additional information considered relevant but unclear or missing in the study [27,28,29, 37].

Data analysis, presentation, and dissemination

The screening strategies will be described based on various characteristics, including the scale used, the number of items or questions, the scoring system adopted, and the reported time for completing the assessment. Additionally, the characteristics of the eligible population for screening will be defined, as well as the contexts for applying the instrument, including when, how, and where the strategy should be applied. The collected evidence will be characterised and summarised according to the PCC framework and grouped into categories aligned with the objectives of this scoping review. Furthermore, specific approaches for special populations will be described, as well as implementation lessons learned as described by the study authors.

Additionally, identified gaps in the current literature will be presented. The results will be presented in a table with a narrative summary describing the principal results and graphs. This information will be used in analyses stratified by race/ethnicity, sex, age group, and socioeconomic and cultural context. Geographical information will be represented on maps to visualise the distribution of screening strategies by country. Quantitative data will be synthesised using frequencies and absolute numbers. For qualitative studies, the main reported themes will be presented and grouped according to categories of health professionals’ perceptions and participants’ ages (adolescents and adults).

The research results will be shared in various ways to reach funding agencies, the scientific community, policy-makers, and relevant service providers through research reports, article publications, and presentations at scientific events related to the theme. For communication to the general public, materials such as infographics with simple and direct language of the main results will be disseminated on social media, as well as press releases and instructional cards and reels.

Discussion

This work will be the first scoping review dedicated to investigating screening strategies for EDs, specifically in the context of PHC. Furthermore, this review aims to address gaps in the literature by providing an account of the characteristics and analysis of the quality and robustness of psychometric tests and the diagnostic value of these strategies.

This section discusses the potential impact of the findings of this scoping review, outlining the literature to identify, describe, and evaluate all instruments and methodologies for estimating the risk of eating disorders in PHC. Importantly, this review aims to fill this knowledge gap and is also oriented towards providing practical recommendations for selecting the most appropriate instrument for use in PHC. Additionally, we aim to discuss the implications of these findings for future research, encouraging the continuous development and improvement of ED screening strategies in the context of PHC. In this way, this research can provide valuable insights into ED screening in PHC, contributing to the improvement of the research process and ensuring that the review results in practical guidance for health care professionals and researchers dedicated to the field of EDs.

Data availability

The datasets analysed during this study will be accessible upon reasonable request from the corresponding author.

Abbreviations

AN:

Anorexia nervosa

ARFID:

Avoidant/restrictive food intake disorder

BED:

Binge eating disorder

BN:

Bulimia nervosa

CINAHL:

Cumulative Index to Nursing and Allied Health Literature

ED:

Eating disorder

JBI:

Joanna Briggs Institute

LILACS:

Latin American and Caribbean Health Sciences Literature

PHC:

Primary health care

PRISMA-P:

Preferred Reporting Items for Systematic reviews and Meta-Analyses Protocol

PRISMA-ScR:

PRISMA extension to Scoping Reviews

ScR:

Scoping review

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Acknowledgements

The authors acknowledge the financial support provided by the Coordination for the Improvement of Higher Education Personnel (CAPES), Brazil, Code 001.

Funding

This work was supported by the National Council for Scientific and Technological Development (CNPq) and the Department of Science and Technology of the Secretariat of Science, Technology, Innovation and Strategic Inputs in Health of the Ministry of Health (Decit/SCTIE/MS). Number process: 408315/2022–9.

Author information

Authors and Affiliations

  1. Department of Nutrition Science, Nutrition School, Federal University of Bahia, Salvador, Bahia, 40110-907, Brazil

    Mônica Leila Portela de Santana, Karine Lima Curvello-Silva, Carla de Magalhães Cunha & Priscila Ribas de Farias Costa

  2. Graduate Program in Food, Nutrition and Health, Nutrition School, Federal University of Bahia, Salvador, Bahia, 40110-907, Brazil

    Lisane da Silva Oliveira

  3. Nutrition School, Federal University of Bahia, Salvador, 40110-907, Brazil

    Isabelle de Jesus Peneluc Menezes

  4. Center for the Integration of Dataand Knowledge for Health (CIDACS/Fiocruz – NIH – Harvard), Salvador, Brazil

    Patrícia Fortes Cavalcanti de Macêdo

  5. Salvador’s Municipal Health Office, Salvador, Brazil

    Aline Monteiro dos Santos Ruas

  6. Department of Nutrition, Faculty of Health Science, University of Brasília, Brasília, Brazil

    Renata Alves Monteiro

  7. Université de Montréal — École de Santé Publique, Montreal, Canada

    Louise Potvin

  8. London School of Hygiene and Tropical Medicine, London, UK

    Sanjay Kinra

  9. Campus Health Library, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil

    Gesner Francisco Xavier Júnior

Authors
  1. Mônica Leila Portela de Santana
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  2. Lisane da Silva Oliveira
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  3. Karine Lima Curvello-Silva
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  4. Carla de Magalhães Cunha
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  5. Isabelle de Jesus Peneluc Menezes
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  6. Patrícia Fortes Cavalcanti de Macêdo
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  7. Aline Monteiro dos Santos Ruas
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  8. Renata Alves Monteiro
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  9. Louise Potvin
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  10. Sanjay Kinra
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  11. Gesner Francisco Xavier Júnior
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  12. Priscila Ribas de Farias Costa
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Contributions

The authors confirm their contribution to the paper as follows: Responsible for heading this project, conceptualising, and drafting the protocol: MLPdS. They assisted with the conceptualisation of the protocol and critical reviews of the writing process of this manuscript: PRFC, CdMC, LdSO, KLC-S, IdJPM, PMF, AMdSR, RAM, and GFXJ. All authors critically reviewed and approved the final version of the manuscript.

Corresponding author

Correspondence to Mônica Leila Portela de Santana.

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de Santana, M.L.P., Oliveira, L.d., Curvello-Silva, K.L. et al. Exploring validated strategies for screening for eating disorders in adolescents and adults in primary health care: a scoping review protocol. Syst Rev 13, 288 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13643-024-02711-0

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13643-024-02711-0

Keywords

Systematic Reviews

ISSN: 2046-4053