Exploration of Barriers to Treatment for Patients with Eating Disorders in Chile

Exploration of Barriers to Treatment for Patients with Eating Disorders in Chile | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploration of Barriers to Treatment for Patients with Eating Disorders in Chile Felipe Castañeda, Jaime Cerda, Raúl Jara, Francisca Riestra, Pascuala Urrejola, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3909214/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Oct, 2024 Read the published version in Journal of Eating Disorders → Version 1 posted 9 You are reading this latest preprint version Abstract Background Eating disorders (EDs) are associated with high morbidity and mortality, affecting predominantly young people and women. A delay in starting treatment is associated with chronic and more severe clinical courses; however, evidence on barriers and facilitators of access to care in Latin America is scarce. We aimed to identify barriers and facilitators of ED treatment in Chile from the perspective of patients, relatives, and health professionals. Methods Qualitative approach through semi-structured interviews with patients, their relatives, and health professionals. Participants were recruited from two ED centers in Santiago, Chile (one public and one private). Analysis was mainly based on Grounded Theory, using MAXQDA software. Results 40 interviews were conducted (n = 22 patients, 10 relatives, and 8 health professionals). The mean age of patients was 21.8 years, while the mean duration of untreated ED was 91.4 months (median 70 months). Five categories emerged with intersections between them: patient (P), family and social environment (FSE), health professionals (HP), healthcare system (HCS), and social and cultural context (SCC). Relevant barriers appeared within these categories and their intersections, highlighting a lack of professional knowledge or expertise, cultural ignorance or misinformation regarding EDs, and patient's ego-syntonic behaviors. The main facilitators were patients’ and relatives’ psychoeducation, recognition of symptoms by family members, and parents taking the initiative to seek treatment. Conclusions This study provides information regarding access to treatment for patients living with EDs in Chile. A practical public health approach should consider the multi-causality of delay in treatment and promoting early interventions. Eating disorders access to treatment early intervention public health Chile Figures Figure 1 Figure 2 Plain English Summary Eating disorders (EDs) may severely affect the daily functioning of people enduring them. A delay in starting treatment is associated with a disease that is more difficult to treat. To our knowledge, there are no published studies carried out in Latin America exploring factors influencing treatment initiation in EDs patients. This study aimed to identify facilitators of and barriers to treating patients with EDs in Chile. We interviewed patients (n = 22), their relatives (n = 10), and health professionals (n = 8) from a private and a public center in Santiago, Chile. Our analysis showed that the main barriers to starting treatment were the lack of professional knowledge in ED, the monetary cost of illness, and cultural misinformation. Facilitators were related to the role of the family in recognizing and addressing the disease while being educated in EDs by professionals. This study helps to provide data about treatment access in developing countries. While facilitators and barriers were similar to others reported in the literature, the untreated ED’s duration was longer. It is essential to address these barriers to provide access to treatment more efficiently and prevent severe and enduring forms of disease. Background Eating disorders (EDs) have the highest mortality among mental illnesses [ 1 ], due to impairment of physical health or psychological complications [ 2 ]. Paradoxically, most individuals with EDs do not seek treatment [ 3 , 4 ]. A delay in starting treatment for an ED is a marker for a worse prognosis [ 5 ] and can lead to an 'entrenched' form of the disease, which is often more challenging to treat [ 3 ]. Evidence shows that early intervention leads to better outcomes in patients with EDs [ 6 , 7 ]. Current research suggests that stigma, lack of knowledge about mental disorders, negative past experiences with professionals, and lack of support from the social environment, among other barriers, may hinder access to treatment in EDs [ 8 ]. However, the literature remains scant and lacks data on factors that influence treatment initiation in developing countries. According to the Global Burden of Disease Study 2019 [ 9 ], Chile has the highest prevalence of both anorexia nervosa (AN) and bulimia nervosa (BN) in Latin America (0.09% and 0.27%, respectively) [ 10 ]. Treating patients with EDs involves a high economic cost for families and the system as a whole [ 2 , 11 ]. Moreover, patients with EDs may present a broad spectrum of complications, which tend to be particularly serious in patients with AN [ 12 ]. Existing literature shows that a more severe clinical course may be associated with a chronic ED [ 13 ]. A study of 41 patients treated in a specialized ED unit in Chile found that the clinical severity of the disorder was associated with a delay in finding treatment [ 14 ]. Thus, the need to study the factors that affect access to treatment is important, particularly in countries where access to mental health care is not widespread [ 14 ]. There is a need to address EDs in Latin America, as there are few published studies regarding epidemiology, cultural factors [ 15 ], role of ethnicity or culture-related differences as risk factors for EDs [ 10 ]. This knowledge gap is even greater when referring to barriers to access to treatment. To our knowledge, no studies have yet been published about factors that influence treatment initiation in ED patients from Latin American countries [ 16 ]. Considering that EDs are identified in primary care or pediatric consultations [ 17 ], it is necessary to know the availability of referral services. Also, several studies have evaluated the knowledge and skills of health professionals in diagnosing and treating patients with EDs [ 18 – 22 ]. The Chilean healthcare system has a mixed financing scheme, with both public and private sources. The public system is financed through state funds and mandatory individual contributions, while the private system is financed by individual insurance based on the risk of the insured [ 23 ]. High-risk and poorer individuals are more prevalent in the public system, increasing inequalities by placing increased demand on limited resources [ 24 ]. On the other hand, the private system is highly susceptible to financial catastrophe due to the high out-of-pocket expenditures for families [ 24 ]. Moreover, the Chilean healthcare system risks collapsing entirely following increased clashes between the national judiciary and private insurers [ 25 ]. We included the experiences of patients and families from private and public healthcare to address system-specific facilitators and barriers. This study aimed to identify barriers and facilitators of access to treatment for patients with EDs in Chile from the perspective of patients, family members, and health professionals. The theoretical framework of this study used evidence from other countries because current data from Latin America remains poor on treatment initiation and first contact in EDs. Additionally, replicating a recent German study [ 26 ], this investigation quantitatively estimated the duration of the untreated eating disorder (DUED). Methods Design and setting The study has a qualitative, multi-informative design. Data was collected from semi-structured interviews (N = 40) with participants from both a private Chilean healthcare network and a public hospital. A specific interview script was designed for the three study groups: patients, family members, and health professionals. We worked primarily under a Grounded Theory approach [ 27 , 28 ], reaching theoretical saturation after analyzing sufficiently heterogeneous collected data. Data collection and analysis were both conducted following the Consolidated Criteria for Reporting Research (COREQ) recommendations [ 29 ]. We also followed the Standards for Reporting Qualitative Research [ 30 ]. Participants Heterogeneous patients regarding gender, age, socioeconomic status, city of residence, migrant status, and specific ED were included until a saturation point was reached. Participants were initially chosen by purpose. As interviews were conducted and transcribed, a data matrix was created in Excel; this helped to systematize information and generate selection criteria for the following participants. With the help of specialized ED teams, it was possible to facilitate the targeted search for patients whose “a priori” information could help fill content gaps. Thus, theoretical saturation was reached with 40 interviews, which were distributed among 22 patients, 10 family members, and 8 health professionals. The patient’s inclusion criteria were being at least 14 years old, diagnosed according to DSM-5, having started treatment for the first time within the last two years, and with at least 5 or more outpatient treatment sessions, or 7 days of inpatient treatment. Exclusion criteria were severe psychiatric or somatic symptoms that may affect participation, having a previous treatment for the ED, and active drug use. The two-year limitation for starting treatment was to reduce the possible effect of recall bias [ 31 ]. To exclude early treatment dropouts, five outpatient sessions or seven days of inpatient treatment were required [ 32 ]. During the interviews, patients were asked about a family member and a healthcare provider who were significant in their treatment, and subsequently, they were contacted. No exclusion criteria were previously defined for family members and health professionals. This study was a thesis for a master’s degree in public health and received approval from the ethics committee of the Pontificia Universidad Católica de Chile and the Southeast Metropolitan Health Service in Santiago. Additionally, before starting recruitment, we obtained authorization from San Carlos de Apoquindo Clinic and Dr. Sótero del Río Hospital medical management. Informed consent was obtained from all participants. For those under 18 years of age, parental consent and assent from the minor was obtained. Data collection Patients were recruited from each medical center by their health professionals. If they accepted participation, they were contacted by the lead researcher and sent the informed consent form, after which an interview was scheduled. Patients from the public hospital were recruited at the end of their medical appointment by one of the researchers. Compliance with inclusion criteria and exclusion criteria was verified. Relatives and health professionals were contacted and interviewed after patients named them as significant for their treatment and had given their consent. Interviews were conducted via Zoom or in-person. Once the interviews and their corresponding audio files were completed, they were stored on a password-protected electronic platform. The verbatim transcription of the recordings was made using Microsoft Word by the leading researcher and two research assistants. After transcribing each interview, the Microsoft Word file was exported in a PDF on the same platform. Transcripts were then uploaded to MAXQDA. Specific interview scripts were designed for patients, relatives, and health professionals. The first part of the script was designed to obtain information from participants, including their socio-demographic background. The second part was used to identify facilitators and barriers. An attempt to quantitatively estimate the DUED was made for patients. It was calculated by subtracting the treatment start date from the onset of symptoms date. If the patient remembered the specific month and year of the beginning of symptoms, that date was recorded. However, if they did not recall the exact date, an average of two approximate dates was calculated (for example, "between January and July 2011" was recorded as April 2011). The treatment starting date was confirmed by the healthcare provider. The script was based on a German study [ 26 , 32 ]. The leading researcher contacted Dr. Antje Gumz before starting the study and after its completion. Methodological aspects were adapted to the local context. Data analysis Analysis was carried out in Microsoft Excel and MAXQDA, co-occurring with data collection. Thus, from the beginning of recruitment, an Excel spreadsheet was kept with the participants' information, which helped to perform a purposeful selection of participants to reach theoretical saturation. There were three modes of coding the interviews: open, axial, and selective coding. As the interviews were conducted, the categories of analysis emerged. An attempt was made to generate a tree of codes that adequately represented the content of the interviews, which was completed in the analysis's final stages. The description of sociodemographic variables and the estimation of DUED were conducted using descriptive analysis with measures of central tendency, dispersion, and frequencies through Excel. During the analysis process, an audit of five interview recordings was performed by an external reviewer as part of a reliability check. Results Sociodemographic characteristics Overall, 40 interviews were conducted: 22 patients, 10 relatives, and 8 health professionals. 35 were conducted using Zoom, while 5 were in-person. 90% of the interviewees were women (n = 36). No participant required psychological support during the interview process. Table 1 shows the demographic and clinical characteristics of patients, relatives, and health professionals. Diagnostic criteria and BMI upon entering treatment were reported by the professional. Table 1 Sample characteristics Demographic or clinical characteristic Sample characteristics (n = 40) Patients (n = 22) Gender Female: n = 21 Male: n = 1 Geographical origin Northern region of Chile: n = 1 Central region of Chile: n = 18 Southern region of Chile: n = 3 Initial treatment Outpatient: n = 17 Inpatient: n = 5 Living with parents With both parents: n = 11 Only with mother: n = 6 With neither parent: n = 5 Highest education level completed (personal) Primary education: n = 8 Secondary education: n = 10 Short-cycle tertiary education: n = 2 Bachelor’s degree: n = 2 Highest education level completed (parents) Secondary education: n = 9 Bachelor’s degree: n = 13 Health insurance Private = n = 15 Public: n = 7 Migrant status Yes: n = 1 Identification with indigenous group Yes: n = 1 Eating disorder diagnosis Anorexia nervosa: n = 10 Restrictive subtype: n = 7 Purgative subtype: n = 3 Bulimia nervosa: n = 4 OSFED: n = 3 Atypical anorexia: n = 3 Binge-eating disorder: n = 2 UFED: n = 2 ARFID: n = 1 Age (at the time of interview) M = 21.8 years (SD = 7.46) BMI at the start of treatment M = 19.67 kg/m 2 (SD = 5.05) DUED M = 91.41 months (SD = 82.28) Median = 70 months (Range: 8–298) Relatives (n = 10) Relationship with patient Relative 1: Mother of a 16-year-old girl Relative 2: Mother of a 19-year-old girl Relative 3: Mother of a 19-year-old girl Relative 4: Mother of a 16-year-old girl Relative 5: Mother of a 16-year-old girl Relative 6: Mother of a 16-year-old girl Relative 7: Mother of a 17-year-old girl Relative 8: Mother of a 33-year-old woman Relative 9: Sister of a 22-year-old woman Relative 10: Husband of a 44-year-old woman Geographical origin Central region of Chile: n = 7 Southern region of Chile: n = 3 Age (at the interview) M = 51.7 years (SD = 5.19) Health professionals (n = 8) Gender Female: n = 6 Male: n = 2 Profession Physician: n = 4 Psychiatrist: n = 3 Pediatrician: n = 1 Nutritionist: n = 2 Psychologist: n = 2 Specialization in ED Yes: n = 6 No: n = 2 Working in healthcare subsystems Only in private system: n = 6 Both in public and private: n = 2 Age (at the time of interview) M = 39.9 years (SD = 10.33) ( Please insert Table 1 near here ) The geographic location of patients may serve to illustrate the physical inaccessibility of specialized ED services in Chile (Fig. 1). While 14 of 22 patients lived in Santiago at the time of the interview, all healthcare services included in the study were in Santiago. That means, 8 of 22 patients received a long-distance treatment. (Fig. 1: Geographical origin of the patient sample within Chile ) Emerging categories, facilitators, and barriers An open coding process was first performed using MAXQDA for qualitative analysis. The category tree was then refined through selective coding. The final model included 1714 codes, which were divided into 5 main categories (Fig. 2): patient (P), family and social environment (FSE), health professionals (HP), healthcare system (HCS), and social and cultural context (SCC). (Fig. 2: Emerging categories model and number of codes ) Considering the interactions within the model, the specific value of each intersection between categories was emphasized. Thus, for example, the codes that pointed to the interaction between the patient and family environment were grouped at the intersection “FSE + P”. The positive or negative value that participants gave to each factor mentioned during the interview was carefully evaluated to identify facilitators and barriers. Therefore, depending on the context, some aspects could function both as facilitators and barriers (for example, a positive experience with a health professional versus a negative one). An F (facilitator) or B (barrier) was added to each code for being either a facilitator or barrier and was grouped into a model category. Tables 2 and 3 show 15 of the most important barriers and facilitators respectively. Also, to favor the replicability of this type of research, the results are presented similarly to Kästner et al. [ 26 ]. Table 2 Top 15 barriers to treatment initiation. Barriers Category Number of Codes Number of Interviews (%) a Lack of professional knowledge or expertise C - HCS 140 34 (85) Monetary cost of treatment HCS 104 31 (77.5) Cultural ignorance or misinformation SCC 80 32 (80) Patient’s ego-syntonic behaviors P 101 31 (77.5) Family does not recognize signs or symptoms FSE – P 79 29 (72.5) Lack of specialists or teams for ED treatment HCS 66 28 (70) Stigma or stereotypes about ED SCC 41 22 (55) Geographic location of treatment services SCC 63 19 (47.5) Normalization of maladaptive eating patterns SCC 34 21 (52.5) Family does not understand or support FSE – P 36 18 (45) Not being able to talk about (my) eating problems P – FSE – C 30 21 (52.5) Long-standing ED P 31 18 (45) Lack of multidisciplinary team in (my) treatment C - HCS 29 17 (42.5) Long and/or difficult therapeutic process P – FSE 35 13 (32.5) Not knowing where or who to turn to P - FSE – C - HCS 26 17 (42.5) Positive value of society on female thinness SCC 29 16 (40) Notes: a Percentage of all interviews (n = 40). Table 3 Top 15 facilitators of treatment initiation. Facilitators Category Number of Codes Number of Interviews (%) a Psychoeducation for patients and their families C – P - FSE 87 27 (67.5) Parents taking the initiative to find treatment FSE – P 51 27 (67.5) Recognition of symptoms by the family FSE - P 48 27 (67.5) Understanding or support of the family group FSE - P 66 25 (62.5) Referral or recommendation to treatment HCS - C 44 25 (62.5) Presence of multidisciplinary team in (my) treatment C - HCS 41 25 (62.5) Clinical worsening P - HCS 48 23 (57.5) Insight or patient’s ED awareness P 42 24 (60) Professional knowledge or expertise C - HCS 31 19 (47.5) Having financial resources for access FSE - P 25 19 (47.5) Being able to talk about (my) eating problems P – FSE - C 25 18 (45) There’s a greater awareness or visibility of ED SCC 27 15 (37.5) Quick access from the referral HCS 19 15 (37.5) Inpatient treatment to access specialized management HCS 23 14 (35) Health professional empathy C 16 12 (30) Notes: a Percentage of all interviews (n = 40). (Please insert Table 2 and Table 3 near here ) Main findings 1080 barriers and 634 facilitators (63% and 37%, respectively) were coded. This section addresses, using direct quotes, the practical impact or value of the main facilitators and barriers in the model. Patient The main barrier within the patient category was ego-syntonic behaviors (101 codes; 77.5% of interviews). Ego-syntonic features of EDs entail symptoms of concealment, "not wanting to receive help" or "not wanting to get better." One patient describes it as follows: Patient 19: “You don't want to leave the disease. It’s your comfort zone and a life you’re used to. So, getting out of it is difficult, and even more so when you've been involved in this for so long." This quote is also linked to one of the main barriers in the patient category, that is, the presence of a longstanding ED (31 codes; 45% of interviews). The most mentioned facilitator in this category was insight or awareness of the disease (42 codes; 60% of interviews). This facilitator could be seen as a logical counterpart to ego-syntonic behaviors, values, and feelings, but requires a complex process of personal understanding. Patient 3: “I wanted to get better. I truly wanted to get out of it. So, my perseverance made my parents look for places (for treatment).” Intersection: Patient and Healthcare System At this level, worsening symptoms are the main facilitator for starting treatment (48 codes; 57.5% of interviews). There was a heterogeneity of "worsening" symptoms within the interviews (for example, from a change in self-perceived mental health status to cardiorespiratory arrest). However, in all cases, it was a factor that favorably affected access to treatment. Patient 17: "If I hadn't come to the emergency room due to malnutrition, we would never have started (treatment)." Intersection: Patient and Family and Social Environment Families were most frequently mentioned in the interactions between the patient and the environment, both as barriers and facilitators (see barriers 5 and 10 of Table 2 and facilitators 2–4 of Table 3 ). Family members are part of the patient's care system, but at the same time, they may favor the maintenance of the disease. Therefore, it’s essential for health professionals to seek a therapeutic alliance with parents, empowering them to recognize the disease and to cope with it. The first two quotes address the family as a facilitating factor, while the third places it as a barrier. Patient 9: “My mother is the one who always supports me and tells me that I must keep going, that together we can make it. That helped me the most to start treatment.” Patient 5: “My friends didn't notice, but my family did. They noticed my weight loss. My face looked tired, with dark circles. So, they worried more and more. I saw that my mom had a hard time when she saw me doing poorly. I think that influenced me to seek treatment.” Patient 19: “They (my parents) realized that I wasn't eating, and at one point, they even congratulated me for not eating so much because I was losing weight, and ‘that way I looked prettier.’ That's why it was hard for me to tell them that ‘I feel bad eating’, and to find a specialist." Intersection: Patient, Family and Social Environment, and Health Professionals Clinicians, patients, and their families had different levels of understanding of EDs. Psychoeducation is a crucial facilitator for starting treatment and adherence (87 codes, 67.5% of interviews). It emphasizes, among other aspects, the need for prompt care due to the high risk of chronicity. As EDs are mostly ego-syntonic mental disorders, parents must oversee feeding the patient, and they must learn to identify and change dynamics that may perpetuate the illness. The mother of a patient with AN relates the effect of psychoeducation as follows: Relative 3: “First, we didn’t do it well; We did not follow the meal plan as told, because I did not understand its importance. Until one day, the doctor told me, ‘You have to fight the disease.’ ‘You have to be very strict.’ And then it made sense. So, I told my husband, ‘The doctor told me that we have to fight, and the meal plan has to be followed.’ In other words, do not give way to this disease so that it cannot beat us. We beat it.” Intersection: Health Professionals and Healthcare System The most mentioned barrier in the whole analysis was the professionals’ lack of knowledge or expertise (140 codes; 85% of interviews). Throughout the interviews, this lack of knowledge was brought up regarding visiting professionals who failed to identify the disease or who identified it but did not know how to manage it. Patient 8: “Ignorance about the disease. Not only from my parents but from all doctors in general. […] We visited many doctors, and no one knew anything.” Patient 22: “I had a psychiatrist, but he misunderstood what was happening and didn’t know how to help me either. […] In fact, he told me that everything was fine if I had a BMI of 16 (kg/m 2 ). If I reached a BMI of 14 (kg/m 2 ), then I had to worry.” In some cases, patients and their families received treatment from more than one non-specialist treating professional who handled the ED inadequately. Also, this may be related to the apparent lack of medical education on EDs in undergraduate studies, which was mentioned by some professionals. Health professional 5: “There is also the phenomenon that non-specialists take these cases, and the literature says that not only is this not recommended, but it is iatrogenic. It can negatively affect that patient, even if the professional's intention is good.” Health professional 3: “I think that (medical) undergraduate formation is scarce in EDs. What I have seen in undergraduate programs is that, usually, there is a class in the fourth or fifth year on EDs, and that is it.” The most relevant facilitators at this intersection were treatment by a multidisciplinary team (41 codes; 62.5% of interviews) and a referral to a specialized ED unit (44 codes; 62.5% of interviews). Moreover, participants highlighted the role of specialists and primary care physicians in the early detection of EDs and timely referral to a specialized multidisciplinary team. Relative 2: “Thank God she had the chance to receive a multidisciplinary treatment. Not just the dietitian, the psychologist, or the physicians. But all of them working together.” Patient 18: “I was referred from primary care. I told the doctor that I ate and vomited very often, almost daily. She got worried and referred me here with a psychiatrist.” Healthcare System In this sample, the Chilean healthcare system was perceived as offering more barriers than facilitators for patients with EDs. The high financial cost of treatment in the private system, which houses most ED specialists in the country, was consistently mentioned as a barrier (104 codes; 77.5% of interviews). This may be explained due to the need for a multidisciplinary team and short intervals between appointments, the lack of reimbursement by insurers, and the high cost of inpatient treatment. Relative 1: “We are talking about four expensive specialists. Some people simply cannot access (treatment). I am spending around 600,000 pesos* a month.” *Approximately 650 USD as of January 2024. Patient 22: “The cost of this is enormous. I feel hyper-privileged to do it because I couldn’t afford it, and my family is paying. My mom is trying to sell the house to help my sister with the cost of this because I’ve been hospitalized for two months. It is unthinkable. I don’t want to calculate what’s coming.” The geographic location of specialized health services is another barrier in the healthcare system (63 codes; 47.5% of interviews). Although this barrier was not mentioned by participants from Santiago, it was extensively brought up by patients from other regions. Patient 9: “We didn’t find many things in the Valparaíso Region. The only hope we had was Santiago. [...] Where I am (receiving treatment), many people must travel to Santiago. There are no other places to receive all this help.” Furthermore, this barrier is linked to another negative aspect of the healthcare system: the lack of specialists (66 codes; 70% of interviews). Patient 6: “Not many professionals specialize in these kinds of disorders. It was hard for me to find (a specialist). In fact, I could say that I never found one until I was hospitalized.” Health professional 4: “Most of the specialists work in Santiago, which makes (the situation) more dramatic. These disorders require a degree of specialization, so, primary care teams or even mental health teams in other regions do not have the expertise to handle EDs correctly.” Social and Cultural Context Chilean society has yet to shift toward a culture that adequately recognizes and addresses EDs. Although in recent years there has been greater visibility towards EDs, and this was recognized as a facilitator in several interviews (27 codes; 37.5% of interviews), cultural ignorance and misinformation still exist (80 codes; 80% of interviews). Relative 3: “They treated us badly as parents because I felt they blamed us. The disease was very unknown. They couldn't understand how we couldn't feed our daughter." Health professional 4: "The nonrecognition shows that there is a lot of ignorance in our society regarding eating disorders." Stigma (41 codes; 55% of interviews) and society's positive value of female thinness (29 codes; 40% of interviews) are linked to misinformation. Those factors may perpetuate harmful behaviors and affect access. Patient 2: “The social stigma is that you must be thin. In the end, you may know you have an eating disorder, but you don't want to get better because you feel more accepted in society. Nobody is going to judge you if you are skinny or if you fit into social standards." Discussion This qualitative research explored facilitators and barriers to access to treatment in patients with EDs in Chile. Interviewing three different groups allowed us to identify factors that affect access to care. Furthermore, it was possible to establish that each group tended to mention more barriers and facilitators specific to their own perspective or field, which was also reported in the study by Kästner et al. [ 26 ]. For example, patients mostly described ego-syntonic behaviors as barriers, while health professionals emphasized the lack of knowledge or expertise. Meanwhile, the most important facilitators for families were the recognition of EDs and their own involvement in the treatment of their relatives. Interestingly, each of the five main barriers found in this study represents a different category or intersection of the model proposed in the analysis, reinforcing the idea that the problem must be addressed from different angles. With regards to the five main facilitators, four emphasize the role of families. In EDs, family members play an essential role in the recovery of patients, an aspect that has been emphasized in other qualitative studies [ 33 – 35 ]. The barriers and facilitators found in the analysis are relatively similar to those found in other studies, such as the systematic review by Ali et al [ 36 ] and the Scoping review by Nicula et al [ 8 ]. The geographic barrier, which did not appear in these but was found in our study, was addressed in three studies from Australia and New Zealand [ 37 – 39 ]. Another barrier found in this study was the existence of a longstanding ED (45% of the interviews). Some data suggest that a prolonged clinical course of the ED may be a consequence of late treatment initiation (40). However, to our knowledge, this is the first study that also considers it as a barrier. A longstanding ED may delay the start of treatment and perpetuate the illness, as the difficulty of seeking help is accentuated due to the ego-syntonic nature of symptoms. Only one patient interviewed did not refer to her mother as an important figure in the therapeutic process. She was the sample's oldest patient, and instead, she referred to her husband. This is in accordance with data from the international literature, where fathers are less involved than mothers in treatment [ 35 , 41 , 42 ]. The average DUED estimated in our study was 7.6 years (median 5.8 years), representing, to our knowledge, the longest time published in the literature on ED. The clinical characteristics of the sample could partially explain this finding since this study included patients with different types of EDs. Most publications have been done in patients with AN. A recent systematic review found that the DUED for AN was 2.5 years, while for BN it was 4.4 years, and for binge-eating disorder 5.6 years [ 7 ]. After the studies by Kästner and McNicholas [ 32 , 43 ], this is the third qualitative publication that explores barriers to treatment for patients with EDs from the perspective of patients, family members, and health professionals. To our knowledge, this is the first study done in a developing country. This may contribute to filling an important gap in the literature since all the studies published to date have been conducted in countries with greater resources. Limitations Most of the study limitations are due to the small sample size. Although there was theoretical saturation, three variables could not be explored exhaustively (migrant status, indigenous people, and male gender). Patient gender may be important, as men with EDs are often less recognized, less treated, and more stigmatized [ 44 ]. Primary healthcare professionals were not included. Moreover, the health professionals included in the study were mainly ED specialists working in a private clinic, which is uncommon for the Chilean healthcare system. Although few professionals from the public healthcare system were interviewed, the inclusion of specialists mostly from the private system represents the existing gap between the public and private healthcare systems in Chile. Even though this study includes patients and families from various regions of Chile, it fails to represent the whole country. There is a bias in the patients’ sample, as they were receiving treatment. The literature shows that patients with EDs, particularly young people, often do not seek treatment and that this “untreated” group may manifest other barriers [ 38 , 45 ]. Second, the sample lacked participants from more extreme regions of the country (such as the Extreme North and Patagonia), which could have further enriched the analysis. Last, there is a significant overrepresentation of patients with private health insurance (68% in the sample versus 16.9% according to official data [ 46 ]). Although the high cost of treatment was one of the most relevant barriers in the analysis, the referral processes and the lack of specialists would have had a greater weight if a representative sample of the Chilean public health insurance system had been included. Public health implications Society is relatively poorly educated about EDs, and public education programs are warranted. There is also a lack of education among health professionals in recognizing symptoms and risk factors of ED that delay diagnosis. Interventions at both levels may be a cornerstone for a public health intervention. Early treatment in EDs is important, considering the early onset age and the neurobiological consequences over time [ 47 ]. Some population-level interventions have shown promising results. In England, FREED (First Episode Rapid Early Intervention) is an evidence-based early intervention model for EDs focused on people aged 16 to 25. It has successfully reduced waiting lists, DUED, and clinical outcomes [ 48 , 49 ]. It has been implemented in 80% of NHS services for adults [ 50 ]. FREED has been modified for use in Australia, where Australian Medicare funds treatment up to 40 therapy sessions and 20 dietitian appointments per year, but with a focus on severe ED [ 51 ]. In contrast, a German program that sought to reduce the DUED of EDs with a systemic public health intervention, including school activities, failed to show statistical significance, probably due to methodological issues [ 52 ]. Cost-effectiveness in developing interventions to prevent and treat EDs has been described when public health systems are involved. An example of this is the English FREED model for intensive treatment of EDs where 4.472 pounds were saved per patient [ 48 ]. In Germany, savings of 2 to 4 euros were estimated per euro invested in AN, and 4 euros saved per euro invested in BN [ 53 ]. It must be emphasized that in both countries, the public health system is superior to Chile's. Future research We suggest conducting more studies on access to treatment for patients with EDs in developing countries. In the long run, low visibility affects the development of public health policies, the physical and mental health of patients, and the perpetuation of stigma. Moreover, it would be useful to encourage epidemiological studies on EDs in Latin America to favor the visibility of the problem and decision-making. Likewise, it would be worthwhile to inquire more into patients' experiences within the public system, male patients’ experiences, and stratifying by sexual orientation and ethnic groups. Previously, we acknowledged that this study didn’t include individuals with EDs who have not accessed specialist care. However, this would be a key point for future studies regarding access to treatment in developing countries like Chile. Furthermore, individuals diagnosed with an ED in primary care who never entered specialist treatment could be a key target group for understanding barriers and developing public policies. Conclusion This study provides qualitative information regarding access to treatment for EDs in Chile. It is the first study of its kind done in a developing country. This may favor the understanding of the phenomenon as a global problem. When dealing with EDs, the entire family unit is distressed. Interventions and proposals should be aimed at modifying family dynamics inside and outside health care to facilitate rapid identification. Likewise, the effect of the barriers inherent to the healthcare system and the inadequate training of professionals should be considered. Finally, it is necessary to reduce DUED to avoid worse clinical outcomes and chronicity of the disorder. Abbreviations AN: Anorexia nervosa. ARFID: Avoidant/restrictive food intake disorder. BMI: Body-Mass-Index. BN: Bulimia nervosa. DSM-5: Diagnostic and Statistic Manual of Mental Disorders – Fifth Edition. DUED: Duration of untreated eating disorder. ED: Eating disorder. EDs: Eating disorders. FSE: Family and social environment. HCS: Healthcare system. HP: Health professionals OSFED: Other specified feeding or eating disorder. P: Patient. SCC: Social and cultural context. UFED: Unspecified feeding or eating disorder. USD: United States Dollar. Declarations Ethics approval and consent to participate Ethical approval for the study was obtained from the Scientific Ethics Committee of both the Pontificia Universidad Católica de Chile (ID: 221024003) and the Southeast Metropolitan Health Service in Santiago. Additionally, before starting recruitment, we obtained authorization from the medical management of the San Carlos de Apoquindo Clinic and the Dr. Sótero del Río Hospital. All participants and, in the case of minor participants, legal guardians provided written informed consent before study inclusion. Consent for publication Every quotation in this publication was obtained prior consent from the respective participant, and in the case of minor participants, from their legal guardians. The anonymity of the data was preserved. Availability of data and materials The anonymized interview transcripts will be made available by the authors upon legitimate request. Competing interests The authors declare that they have no competing interests. Funding The study received no funding. Authors’ contributions FC was the leading investigator, designing the study, conducting the interviews, and analyzing the datasets. JC was the thesis’s advisor, designing the methods, reviewing and editing the text. RJ was the thesis’s coadvisor, participating in the design, coordinating the data collection, and giving feedback for the drafts. FR transcribed interviews, wrote part of the results and discussion, and worked on the final manuscript. PU, MV, MEG, VI, JA, MAD and DC participated in the writing, reviewing and editing process. PK transcribed interviews and worked on the final manuscript. All authors read and approved the final manuscript. Acknowledgments We give special thanks to Jaime Cerda, who was the leading advisor of the thesis, and Melina Vogel, who gave the support of the ED Unit at UC-Christus for this work. Additionally, we would like to thank everyone who helped while developing the study. Alphabetically ordered, they are: Ángela Cruzat, Catalina Cotroneo, Gabriela Espinoza, Karina Husak, María Elena Gumucio, María José Silva, and Pascuala Urrejola. References House J, Schmidt U, Craig M, Landau S, Simic M, Nicholls D, et al. Comparison of specialist and nonspecialist care pathways for adolescents with anorexia nervosa and related eating disorders. International Journal of Eating Disorders 2012;45:949–56. BEAT. The costs of eating disorders: Social, health and economic impacts. London: 2015. 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Dapelo MM, Gil AA, Lacalle L, Vogel M. Severity and Endurance in Eating Disorders: An Exploration of a Clinical Sample From Chile. Front Psychiatry 2020;11. Kolar DR, Mebarak M. An update on the epidemiology of eating disorders in Latin America: current findings and future challenges. Curr Opin Psychiatry 2022. Johns G, Taylor B, John A, Tan J. Current eating disorder healthcare services – the perspectives and experiences of individuals with eating disorders, their families and health professionals: systematic review and thematic synthesis. BJPsych Open 2019;5:e59. Gaete V, López C. Trastornos de la conducta alimentaria en adolescentes: Rol del pediatra. Recomendaciones de la Rama de Adolescencia de la Sociedad Chilena de Pediatría. Rev Chil Pediatr 2020;91:800–8. Anderson K, Accurso EC, Kinasz KR, le Grange D. Residents’ and Fellows’ Knowledge and Attitudes About Eating Disorders at an Academic Medical Center. Academic Psychiatry 2017;41:381–4. Banas DA, Redfern R, Wanjiku S, Lazebnik R, Rome ES. Eating Disorder Training and Attitudes Among Primary Care Residents. Clin Pediatr (Phila) 2013;52:355–61. Linville D, Brown T, O’Neil M. Medical providers’ self perceived knowledge and skills for working with eating disorders: a national survey. Eat Disord 2012;20:1–13. Davidson AR, Braham S, Dasey L, Reidlinger DP. Physicians’ perspectives on the treatment of patients with eating disorders in the acute setting. J Eat Disord 2019;7:1. Girz L, Robinson AL, Tessier C. Is the Next Generation of Physicians Adequately Prepared to Diagnose and Treat Eating Disorders in Children and Adolescents? Eat Disord 2014;22:375–85. Cerda, A.A., García, L.Y., Rivera-Arroyo, J. et al. Comparison of the healthcare system of Chile and Brazil: strengths, inefficiencies, and expenditures. Cost Eff Resour Alloc 2022;20:71 Koch KJ, Cid Pedraza C, Schmid A. Out-of-pocket expenditure and financial protection in the Chilean health care system-A systematic review. Health Policy. 2017;121(5):481-494. Youkee M. Warnings over potential collapse of Chilean health system. Lancet. 2023;401(10376):539 Kästner D, Weigel A, Buchholz I, Voderholzer U, Löwe B, Gumz A. Facilitators and barriers in anorexia nervosa treatment initiation: a qualitative study on the perspectives of patients, carers and professionals. J Eat Disord 2021;9:28. Bonilla-García MÁ, López-Suárez AD. Ejemplificación del proceso metodológico de la teoría fundamentada. Cinta de Moebio 2016:305-15. de la Espriella R, Gómez Restrepo C. Teoría fundamentada. Rev Colomb Psiquiatr 2020;49:127–33. Tong A, Sainsbury P, Craig, J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care 2007:19(6):349-357. O’Brien B, Harris I, Beckman T, Reed D, Cook D. Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Academic Medicine 2014: 89(9):1245-1251. Kjellsson G, Clarke P, Gerdtham U-G. Forgetting to remember or remembering to forget: A study of the recall period length in health care survey questions. J Health Econ 2014;35:34–46. Kästner D, Buchholz I, Weigel A, Brunner R, Voderholzer U, Gumz A, et al. Facilitators and barriers in anorexia nervosa treatment initiation (FABIANA): study protocol for a mixed-methods and multicentre study. BJPsych Open 2019;5:e92. Coelho JS, Suen J, Marshall S, Burns A, Lam P-Y, Geller J. Parental experiences with their child’s eating disorder treatment journey. J Eat Disord 2021;9:92. Wacker EC. Barriers and facilitators to seeking treatment for subclinical eating disorders: The importance of supportive relationships. J Fam Psychother 2018;29:292–317. Ciao AC, Lebow J, VandenLangenberg E, Ohls O, Berg KC. A qualitative examination of adolescent and parent perspectives on early identification and early response to eating disorders. Eat Disord 2022;30:249–66. Ali K, Fassnacht DB, Farrer L, Rieger E, Feldhege J, Moessner M, et al. What prevents young adults from seeking help? Barriers toward help‐seeking for eating disorder symptomatology. International Journal of Eating Disorders. Clark MTR, Manuel J, Lacey C, Pitama S, Cunningham R, Jordan J. Reimagining eating disorder spaces: a qualitative study exploring Māori experiences of accessing treatment for eating disorders in Aotearoa New Zealand. J Eat Disord 2023;11:22. Liu L, Hay P, Conti J. Perspectives on barriers to treatment engagement of people with eating disorder symptoms who have not undergone treatment: a qualitative study. BMC Psychiatry 2022;22:239. Linardon J, Rosato J, Messer M. Break Binge Eating: Reach, engagement, and user profile of an Internet‐based psychoeducational and self‐help platform for eating disorders. International Journal of Eating Disorders 2020;53:1719–28. Piñar-Gutiérrez, A., Dios-Fuentes, E., Remón-Ruiz, P. et al. Description of characteristics and outcomes of a cohort of patients with severe and enduring eating disorders (SE-ED). J Eat Disord 2021;9:135. Ganson KT, Hamilton-Mason J. Not “My Territory:” How Gender Role Socialization Impacts Father Involvement in Caring for a Child with an Eating Disorder. Smith Coll Stud Soc Work 2019;89:18–37. O’Sullivan HM. The influence of gender on paternal involvement in the treatment process of a child or adolescent with an eating disorder. MRes Thesis. University College Cork, 2022. McNicholas F, O’Connor C, McNamara N, O’Hara L. Eating disorder services for young people in Ireland: perspectives of service providers, service users and the general adolescent population. Ir J Psychol Med 2018;35:301–9. Dearden A, Mulgrew KE. Service Provision for Men with Eating Issues in Australia: An Analysis of Organisations’, Practitioners’, and Men’s Experiences. Australian Social Work 2013;66:590–606. Trompeter N, Bussey K, Forbes MK, Mond J, Hay P, Basten C, et al. Differences between Australian adolescents with eating disorder symptoms who are in treatment or not in treatment for an eating disorder. Early Interv Psychiatry 2021;15:882–8. Departamento de Estudios y Desarrollo. Análisis Estadístico del Sistema Isapre con Perspectiva de Género. 2021. Allen KL, Mountford VA, Elwyn R, Flynn M, Fursland A, Obeid N, et al. A framework for conceptualising early intervention for eating disorders. European Eating Disorders Review 2023;31:320–34. Flynn M, Austin A, Lang K, Allen K, Bassi R, Brady G, et al. Assessing the impact of First Episode Rapid Early Intervention for Eating Disorders on duration of untreated eating disorder: A multi‐centre quasi‐experimental study. European Eating Disorders Review 2021;29:458–71. Austin A, Flynn M, Shearer J, Long M, Allen K, Mountford VA, et al. The First Episode Rapid Early Intervention for Eating Disorders ‐ Upscaled study: Clinical outcomes. Early Interv Psychiatry 2022;16:97–105 Richards KL, Hyam L, Allen KL, Glennon D, Di Clemente G, Semple A, et al. National roll‐out of early intervention for eating disorders: Process and clinical outcomes from first episode rapid early intervention for eating disorders. Early Interv Psychiatry 2023;17:202–11. Wade T, Pennesi J-L, Zhou Y. Ascertaining an efficient eligibility cut-off for extended Medicare items for eating disorders. Australasian Psychiatry 2021;29:519–22. Gumz A, Weigel A, Wegscheider K, Romer G, Löwe B. The psychenet public health intervention for anorexia nervosa: a pre–post-evaluation study in a female patient sample. Prim Health Care Res Dev 2018;19:42–52. Bode K, Götz von Olenhusen NM, Wunsch E-M, Kliem S, Kröger C. Population-based cost-offset analyses for disorder-specific treatment of anorexia nervosa and bulimia nervosa in Germany. International Journal of Eating Disorders 2017;50:239–49. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Oct, 2024 Read the published version in Journal of Eating Disorders → Version 1 posted Editorial decision: Revision requested 30 May, 2024 Reviews received at journal 28 May, 2024 Reviewers agreed at journal 05 May, 2024 Reviews received at journal 04 Mar, 2024 Reviewers agreed at journal 13 Feb, 2024 Reviewers invited by journal 13 Feb, 2024 Editor assigned by journal 01 Feb, 2024 Submission checks completed at journal 31 Jan, 2024 First submitted to journal 29 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3909214","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":270264046,"identity":"c3b88fe4-7213-44fd-b752-e54e032a6796","order_by":0,"name":"Felipe 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Network","correspondingAuthor":false,"prefix":"","firstName":"Daniela","middleName":"","lastName":"Costa","suffix":""}],"badges":[],"createdAt":"2024-01-29 16:10:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3909214/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3909214/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40337-024-01104-x","type":"published","date":"2024-10-12T15:57:34+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":50566711,"identity":"1cbff3cc-49de-4cb3-814b-1b8504d71675","added_by":"auto","created_at":"2024-02-02 15:16:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":332325,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003eGeographical origin of the patient sample within Chile\u003c/u\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3909214/v1/3164fb7c2110990ad6ba681b.png"},{"id":50566708,"identity":"6d38ca1a-0bda-4d8a-a80e-78ae120b6f81","added_by":"auto","created_at":"2024-02-02 15:16:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":667341,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003eEmerging categories model and number of codes\u003c/u\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3909214/v1/8ab97a054a87dc5c12c7ac1d.png"},{"id":66597364,"identity":"3dd41179-93e4-4af8-9430-f82914f70519","added_by":"auto","created_at":"2024-10-14 16:10:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2225382,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3909214/v1/1703110b-2576-432f-95c1-fe704e614d68.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploration of Barriers to Treatment for Patients with Eating Disorders in Chile","fulltext":[{"header":"Plain English Summary","content":"\u003cp\u003eEating disorders (EDs) may severely affect the daily functioning of people enduring them. A delay in starting treatment is associated with a disease that is more difficult to treat. To our knowledge, there are no published studies carried out in Latin America exploring factors influencing treatment initiation in EDs patients. This study aimed to identify facilitators of and barriers to treating patients with EDs in Chile. We interviewed patients (n = 22), their relatives (n = 10), and health professionals (n = 8) from a private and a public center in Santiago, Chile. Our analysis showed that the main barriers to starting treatment were the lack of professional knowledge in ED, the monetary cost of illness, and cultural misinformation. Facilitators were related to the role of the family in recognizing and addressing the disease while being educated in EDs by professionals. This study helps to provide data about treatment access in developing countries. While facilitators and barriers were similar to others reported in the literature, the untreated ED\u0026rsquo;s duration was longer. It is essential to address these barriers to provide access to treatment more efficiently and prevent severe and enduring forms of disease.\u003c/p\u003e\n"},{"header":"Background","content":"\u003cp\u003eEating disorders (EDs) have the highest mortality among mental illnesses [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], due to impairment of physical health or psychological complications [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Paradoxically, most individuals with EDs do not seek treatment [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A delay in starting treatment for an ED is a marker for a worse prognosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and can lead to an 'entrenched' form of the disease, which is often more challenging to treat [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Evidence shows that early intervention leads to better outcomes in patients with EDs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Current research suggests that stigma, lack of knowledge about mental disorders, negative past experiences with professionals, and lack of support from the social environment, among other barriers, may hinder access to treatment in EDs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, the literature remains scant and lacks data on factors that influence treatment initiation in developing countries.\u003c/p\u003e \u003cp\u003eAccording to the Global Burden of Disease Study 2019 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], Chile has the highest prevalence of both anorexia nervosa (AN) and bulimia nervosa (BN) in Latin America (0.09% and 0.27%, respectively) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Treating patients with EDs involves a high economic cost for families and the system as a whole [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Moreover, patients with EDs may present a broad spectrum of complications, which tend to be particularly serious in patients with AN [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Existing literature shows that a more severe clinical course may be associated with a chronic ED [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A study of 41 patients treated in a specialized ED unit in Chile found that the clinical severity of the disorder was associated with a delay in finding treatment [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Thus, the need to study the factors that affect access to treatment is important, particularly in countries where access to mental health care is not widespread [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is a need to address EDs in Latin America, as there are few published studies regarding epidemiology, cultural factors [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], role of ethnicity or culture-related differences as risk factors for EDs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This knowledge gap is even greater when referring to barriers to access to treatment. To our knowledge, no studies have yet been published about factors that influence treatment initiation in ED patients from Latin American countries [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsidering that EDs are identified in primary care or pediatric consultations [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], it is necessary to know the availability of referral services. Also, several studies have evaluated the knowledge and skills of health professionals in diagnosing and treating patients with EDs [\u003cspan additionalcitationids=\"CR19 CR20 CR21\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Chilean healthcare system has a mixed financing scheme, with both public and private sources. The public system is financed through state funds and mandatory individual contributions, while the private system is financed by individual insurance based on the risk of the insured [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. High-risk and poorer individuals are more prevalent in the public system, increasing inequalities by placing increased demand on limited resources [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. On the other hand, the private system is highly susceptible to financial catastrophe due to the high out-of-pocket expenditures for families [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Moreover, the Chilean healthcare system risks collapsing entirely following increased clashes between the national judiciary and private insurers [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. We included the experiences of patients and families from private and public healthcare to address system-specific facilitators and barriers.\u003c/p\u003e \u003cp\u003eThis study aimed to identify barriers and facilitators of access to treatment for patients with EDs in Chile from the perspective of patients, family members, and health professionals. The theoretical framework of this study used evidence from other countries because current data from Latin America remains poor on treatment initiation and first contact in EDs.\u003c/p\u003e \u003cp\u003eAdditionally, replicating a recent German study [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], this investigation quantitatively estimated the duration of the untreated eating disorder (DUED).\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and setting\u003c/h2\u003e \u003cp\u003eThe study has a qualitative, multi-informative design. Data was collected from semi-structured interviews (N\u0026thinsp;=\u0026thinsp;40) with participants from both a private Chilean healthcare network and a public hospital. A specific interview script was designed for the three study groups: patients, family members, and health professionals. We worked primarily under a Grounded Theory approach [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], reaching theoretical saturation after analyzing sufficiently heterogeneous collected data.\u003c/p\u003e \u003cp\u003eData collection and analysis were both conducted following the Consolidated Criteria for Reporting Research (COREQ) recommendations [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. We also followed the Standards for Reporting Qualitative Research [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eHeterogeneous patients regarding gender, age, socioeconomic status, city of residence, migrant status, and specific ED were included until a saturation point was reached. Participants were initially chosen by purpose. As interviews were conducted and transcribed, a data matrix was created in Excel; this helped to systematize information and generate selection criteria for the following participants. With the help of specialized ED teams, it was possible to facilitate the targeted search for patients whose \u0026ldquo;a priori\u0026rdquo; information could help fill content gaps. Thus, theoretical saturation was reached with 40 interviews, which were distributed among 22 patients, 10 family members, and 8 health professionals.\u003c/p\u003e \u003cp\u003eThe patient\u0026rsquo;s inclusion criteria were being at least 14 years old, diagnosed according to DSM-5, having started treatment for the first time within the last two years, and with at least 5 or more outpatient treatment sessions, or 7 days of inpatient treatment. Exclusion criteria were severe psychiatric or somatic symptoms that may affect participation, having a previous treatment for the ED, and active drug use. The two-year limitation for starting treatment was to reduce the possible effect of recall bias [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. To exclude early treatment dropouts, five outpatient sessions or seven days of inpatient treatment were required [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. During the interviews, patients were asked about a family member and a healthcare provider who were significant in their treatment, and subsequently, they were contacted. No exclusion criteria were previously defined for family members and health professionals.\u003c/p\u003e \u003cp\u003e This study was a thesis for a master\u0026rsquo;s degree in public health and received approval from the ethics committee of the Pontificia Universidad Cat\u0026oacute;lica de Chile and the Southeast Metropolitan Health Service in Santiago. Additionally, before starting recruitment, we obtained authorization from San Carlos de Apoquindo Clinic and Dr. S\u0026oacute;tero del R\u0026iacute;o Hospital medical management. Informed consent was obtained from all participants. For those under 18 years of age, parental consent and assent from the minor was obtained.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003ePatients were recruited from each medical center by their health professionals. If they accepted participation, they were contacted by the lead researcher and sent the informed consent form, after which an interview was scheduled. Patients from the public hospital were recruited at the end of their medical appointment by one of the researchers. Compliance with inclusion criteria and exclusion criteria was verified. Relatives and health professionals were contacted and interviewed after patients named them as significant for their treatment and had given their consent.\u003c/p\u003e \u003cp\u003eInterviews were conducted via Zoom or in-person. Once the interviews and their corresponding audio files were completed, they were stored on a password-protected electronic platform. The verbatim transcription of the recordings was made using Microsoft Word by the leading researcher and two research assistants. After transcribing each interview, the Microsoft Word file was exported in a PDF on the same platform. Transcripts were then uploaded to MAXQDA.\u003c/p\u003e \u003cp\u003eSpecific interview scripts were designed for patients, relatives, and health professionals. The first part of the script was designed to obtain information from participants, including their socio-demographic background. The second part was used to identify facilitators and barriers.\u003c/p\u003e \u003cp\u003eAn attempt to quantitatively estimate the DUED was made for patients. It was calculated by subtracting the treatment start date from the onset of symptoms date. If the patient remembered the specific month and year of the beginning of symptoms, that date was recorded. However, if they did not recall the exact date, an average of two approximate dates was calculated (for example, \"between January and July 2011\" was recorded as April 2011). The treatment starting date was confirmed by the healthcare provider.\u003c/p\u003e \u003cp\u003eThe script was based on a German study [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The leading researcher contacted Dr. Antje Gumz before starting the study and after its completion. Methodological aspects were adapted to the local context.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAnalysis was carried out in Microsoft Excel and MAXQDA, co-occurring with data collection. Thus, from the beginning of recruitment, an Excel spreadsheet was kept with the participants' information, which helped to perform a purposeful selection of participants to reach theoretical saturation.\u003c/p\u003e \u003cp\u003eThere were three modes of coding the interviews: open, axial, and selective coding. As the interviews were conducted, the categories of analysis emerged. An attempt was made to generate a tree of codes that adequately represented the content of the interviews, which was completed in the analysis's final stages.\u003c/p\u003e \u003cp\u003eThe description of sociodemographic variables and the estimation of DUED were conducted using descriptive analysis with measures of central tendency, dispersion, and frequencies through Excel.\u003c/p\u003e \u003cp\u003eDuring the analysis process, an audit of five interview recordings was performed by an external reviewer as part of a reliability check.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic characteristics\u003c/h2\u003e \u003cp\u003eOverall, 40 interviews were conducted: 22 patients, 10 relatives, and 8 health professionals. 35 were conducted using Zoom, while 5 were in-person. 90% of the interviewees were women (n\u0026thinsp;=\u0026thinsp;36). No participant required psychological support during the interview process.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the demographic and clinical characteristics of patients, relatives, and health professionals. Diagnostic criteria and BMI upon entering treatment were reported by the professional.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSample characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographic or clinical characteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSample characteristics (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients (n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale: n\u0026thinsp;=\u0026thinsp;21\u003c/p\u003e \u003cp\u003eMale: n\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographical origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorthern region of Chile: n\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003cp\u003eCentral region of Chile: n\u0026thinsp;=\u0026thinsp;18\u003c/p\u003e \u003cp\u003eSouthern region of Chile: n\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInitial treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutpatient: n\u0026thinsp;=\u0026thinsp;17\u003c/p\u003e \u003cp\u003eInpatient: n\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving with parents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith both parents: n\u0026thinsp;=\u0026thinsp;11\u003c/p\u003e \u003cp\u003eOnly with mother: n\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e \u003cp\u003eWith neither parent: n\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHighest education level completed (personal)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary education: n\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e \u003cp\u003eSecondary education: n\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003cp\u003eShort-cycle tertiary education: n\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003cp\u003eBachelor\u0026rsquo;s degree: n\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHighest education level completed (parents)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary education: n\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e \u003cp\u003eBachelor\u0026rsquo;s degree: n\u0026thinsp;=\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate\u0026thinsp;=\u0026thinsp;n\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e \u003cp\u003ePublic: n\u0026thinsp;=\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMigrant status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes: n\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIdentification with indigenous group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes: n\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEating disorder diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnorexia nervosa: n\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003cp\u003eRestrictive subtype: n\u0026thinsp;=\u0026thinsp;7\u003c/p\u003e \u003cp\u003ePurgative subtype: n\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003cp\u003eBulimia nervosa: n\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003eOSFED: n\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003cp\u003eAtypical anorexia: n\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003cp\u003eBinge-eating disorder: n\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003cp\u003eUFED: n\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003cp\u003eARFID: n\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (at the time of interview)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;21.8 years (SD\u0026thinsp;=\u0026thinsp;7.46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI at the start of treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;19.67 kg/m\u003csup\u003e2\u003c/sup\u003e (SD\u0026thinsp;=\u0026thinsp;5.05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDUED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;91.41 months (SD\u0026thinsp;=\u0026thinsp;82.28)\u003c/p\u003e \u003cp\u003eMedian\u0026thinsp;=\u0026thinsp;70 months (Range: 8\u0026ndash;298)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelatives (n\u0026thinsp;=\u0026thinsp;10)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelationship with patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelative 1: Mother of a 16-year-old girl\u003c/p\u003e \u003cp\u003eRelative 2: Mother of a 19-year-old girl\u003c/p\u003e \u003cp\u003eRelative 3: Mother of a 19-year-old girl\u003c/p\u003e \u003cp\u003eRelative 4: Mother of a 16-year-old girl\u003c/p\u003e \u003cp\u003eRelative 5: Mother of a 16-year-old girl\u003c/p\u003e \u003cp\u003eRelative 6: Mother of a 16-year-old girl\u003c/p\u003e \u003cp\u003eRelative 7: Mother of a 17-year-old girl\u003c/p\u003e \u003cp\u003eRelative 8: Mother of a 33-year-old woman\u003c/p\u003e \u003cp\u003eRelative 9: Sister of a 22-year-old woman\u003c/p\u003e \u003cp\u003eRelative 10: Husband of a 44-year-old woman\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographical origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentral region of Chile: n\u0026thinsp;=\u0026thinsp;7\u003c/p\u003e \u003cp\u003eSouthern region of Chile: n\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (at the interview)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;51.7 years (SD\u0026thinsp;=\u0026thinsp;5.19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth professionals (n\u0026thinsp;=\u0026thinsp;8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale: n\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e \u003cp\u003eMale: n\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysician: n\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003ePsychiatrist: n\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003cp\u003ePediatrician: n\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003cp\u003eNutritionist: n\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003cp\u003ePsychologist: n\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialization in ED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes: n\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e \u003cp\u003eNo: n\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking in healthcare subsystems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnly in private system: n\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e \u003cp\u003eBoth in public and private: n\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (at the time of interview)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;39.9 years (SD\u0026thinsp;=\u0026thinsp;10.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e(\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePlease insert\u003c/span\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003enear here\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe geographic location of patients may serve to illustrate the physical inaccessibility of specialized ED services in Chile (Fig.\u0026nbsp;1). While 14 of 22 patients lived in Santiago at the time of the interview, all healthcare services included in the study were in Santiago. That means, 8 of 22 patients received a long-distance treatment.\u003c/p\u003e \u003cp\u003e(Fig.\u0026nbsp;1: \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eGeographical origin of the patient sample within Chile\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eEmerging categories, facilitators, and barriers\u003c/h2\u003e \u003cp\u003eAn open coding process was first performed using MAXQDA for qualitative analysis. The category tree was then refined through selective coding. The final model included 1714 codes, which were divided into 5 main categories (Fig.\u0026nbsp;2): patient (P), family and social environment (FSE), health professionals (HP), healthcare system (HCS), and social and cultural context (SCC).\u003c/p\u003e \u003cp\u003e(Fig.\u0026nbsp;2: \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEmerging categories model and number of codes\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eConsidering the interactions within the model, the specific value of each intersection between categories was emphasized. Thus, for example, the codes that pointed to the interaction between the patient and family environment were grouped at the intersection \u0026ldquo;FSE\u0026thinsp;+\u0026thinsp;P\u0026rdquo;.\u003c/p\u003e \u003cp\u003eThe positive or negative value that participants gave to each factor mentioned during the interview was carefully evaluated to identify facilitators and barriers. Therefore, depending on the context, some aspects could function both as facilitators and barriers (for example, a positive experience with a health professional versus a negative one). An F (facilitator) or B (barrier) was added to each code for being either a facilitator or barrier and was grouped into a model category.\u003c/p\u003e \u003cp\u003eTables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e show 15 of the most important barriers and facilitators respectively. Also, to favor the replicability of this type of research, the results are presented similarly to K\u0026auml;stner et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTop 15 barriers to treatment initiation.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of Codes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber of Interviews (%)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLack of professional knowledge or expertise\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC - HCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonetary cost of treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (77.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCultural ignorance or misinformation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatient\u0026rsquo;s ego-syntonic behaviors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (77.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily does not recognize signs or symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFSE \u0026ndash; P\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (72.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLack of specialists or teams for ED treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStigma or stereotypes about ED\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGeographic location of treatment services\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (47.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNormalization of maladaptive eating patterns\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (52.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily does not understand or support\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFSE \u0026ndash; P\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNot being able to talk about (my) eating problems\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP \u0026ndash; FSE \u0026ndash; C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (52.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLong-standing ED\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLack of multidisciplinary team in (my) treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC - HCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (42.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLong and/or difficult therapeutic process\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP \u0026ndash; FSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (32.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNot knowing where or who to turn to\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP - FSE \u0026ndash; C - HCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (42.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePositive value of society on female thinness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNotes: \u003csup\u003ea\u003c/sup\u003e Percentage of all interviews (n\u0026thinsp;=\u0026thinsp;40).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTop 15 facilitators of treatment initiation.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of Codes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber of Interviews (%)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePsychoeducation for patients and their families\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC \u0026ndash; P - FSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (67.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParents taking the initiative to find treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFSE \u0026ndash; P\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (67.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecognition of symptoms by the family\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFSE - P\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (67.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUnderstanding or support of the family group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFSE - P\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (62.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReferral or recommendation to treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCS - C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (62.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePresence of multidisciplinary team in (my) treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC - HCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (62.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical worsening\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP - HCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (57.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInsight or patient\u0026rsquo;s ED awareness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessional knowledge or expertise\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC - HCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (47.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHaving financial resources for access\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFSE - P\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (47.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBeing able to talk about (my) eating problems\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP \u0026ndash; FSE - C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThere\u0026rsquo;s a greater awareness or visibility of ED\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (37.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQuick access from the referral\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (37.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInpatient treatment to access specialized management\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth professional empathy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNotes: \u003csup\u003ea\u003c/sup\u003e Percentage of all interviews (n\u0026thinsp;=\u0026thinsp;40).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(Please insert\u003c/span\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eand\u003c/span\u003e Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003enear here\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eMain findings\u003c/h2\u003e \u003cp\u003e1080 barriers and 634 facilitators (63% and 37%, respectively) were coded. This section addresses, using direct quotes, the practical impact or value of the main facilitators and barriers in the model.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePatient\u003c/h2\u003e \u003cp\u003eThe main barrier within the patient category was ego-syntonic behaviors (101 codes; 77.5% of interviews). Ego-syntonic features of EDs entail symptoms of concealment, \"not wanting to receive help\" or \"not wanting to get better.\" One patient describes it as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatient 19: \u003cem\u003e\u0026ldquo;You don't want to leave the disease. It\u0026rsquo;s your comfort zone and a life you\u0026rsquo;re used to. So, getting out of it is difficult, and even more so when you've been involved in this for so long.\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis quote is also linked to one of the main barriers in the patient category, that is, the presence of a longstanding ED (31 codes; 45% of interviews). The most mentioned facilitator in this category was insight or awareness of the disease (42 codes; 60% of interviews). This facilitator could be seen as a logical counterpart to ego-syntonic behaviors, values, and feelings, but requires a complex process of personal understanding.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatient 3: \u003cem\u003e\u0026ldquo;I wanted to get better. I truly wanted to get out of it. So, my perseverance made my parents look for places (for treatment).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIntersection: Patient and Healthcare System\u003c/h2\u003e \u003cp\u003eAt this level, worsening symptoms are the main facilitator for starting treatment (48 codes; 57.5% of interviews). There was a heterogeneity of \"worsening\" symptoms within the interviews (for example, from a change in self-perceived mental health status to cardiorespiratory arrest). However, in all cases, it was a factor that favorably affected access to treatment.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatient 17: \u003cem\u003e\"If I hadn't come to the emergency room due to malnutrition, we would never have started (treatment).\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eIntersection: Patient and Family and Social Environment\u003c/h2\u003e \u003cp\u003eFamilies were most frequently mentioned in the interactions between the patient and the environment, both as barriers and facilitators (see barriers 5 and 10 of Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and facilitators 2\u0026ndash;4 of Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Family members are part of the patient's care system, but at the same time, they may favor the maintenance of the disease. Therefore, it\u0026rsquo;s essential for health professionals to seek a therapeutic alliance with parents, empowering them to recognize the disease and to cope with it. The first two quotes address the family as a facilitating factor, while the third places it as a barrier.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatient 9: \u003cem\u003e\u0026ldquo;My mother is the one who always supports me and tells me that I must keep going, that together we can make it. That helped me the most to start treatment.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003ePatient 5: \u003cem\u003e\u0026ldquo;My friends didn't notice, but my family did. They noticed my weight loss. My face looked tired, with dark circles. So, they worried more and more. I saw that my mom had a hard time when she saw me doing poorly. I think that influenced me to seek treatment.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003ePatient 19: \u0026ldquo;They (my parents) realized that I wasn't eating, and at one point, they even congratulated me for not eating so much because I was losing weight, and \u0026lsquo;that way I looked prettier.\u0026rsquo; That's why it was hard for me to tell them that \u0026lsquo;I feel bad eating\u0026rsquo;, and to find a specialist.\"\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eIntersection: Patient, Family and Social Environment, and Health Professionals\u003c/h2\u003e \u003cp\u003eClinicians, patients, and their families had different levels of understanding of EDs. Psychoeducation is a crucial facilitator for starting treatment and adherence (87 codes, 67.5% of interviews). It emphasizes, among other aspects, the need for prompt care due to the high risk of chronicity. As EDs are mostly ego-syntonic mental disorders, parents must oversee feeding the patient, and they must learn to identify and change dynamics that may perpetuate the illness. The mother of a patient with AN relates the effect of psychoeducation as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eRelative 3: \u0026ldquo;First, we didn\u0026rsquo;t do it well; We did not follow the meal plan as told, because I did not understand its importance. Until one day, the doctor told me, \u0026lsquo;You have to fight the disease.\u0026rsquo; \u0026lsquo;You have to be very strict.\u0026rsquo; And then it made sense. So, I told my husband, \u0026lsquo;The doctor told me that we have to fight, and the meal plan has to be followed.\u0026rsquo; In other words, do not give way to this disease so that it cannot beat us. We beat it.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eIntersection: Health Professionals and Healthcare System\u003c/h2\u003e \u003cp\u003eThe most mentioned barrier in the whole analysis was the professionals\u0026rsquo; lack of knowledge or expertise (140 codes; 85% of interviews). Throughout the interviews, this lack of knowledge was brought up regarding visiting professionals who failed to identify the disease or who identified it but did not know how to manage it.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatient 8: \u003cem\u003e\u0026ldquo;Ignorance about the disease. Not only from my parents but from all doctors in general. [\u0026hellip;] We visited many doctors, and no one knew anything.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003ePatient 22: \u0026ldquo;I had a psychiatrist, but he misunderstood what was happening and didn\u0026rsquo;t know how to help me either. [\u0026hellip;] In fact, he told me that everything was fine if I had a BMI of 16 (kg/m\u003c/em\u003e \u003csup\u003e \u003cem\u003e2\u003c/em\u003e \u003c/sup\u003e \u003cem\u003e). If I reached a BMI of 14 (kg/m\u003c/em\u003e \u003csup\u003e \u003cem\u003e2\u003c/em\u003e \u003c/sup\u003e \u003cem\u003e), then I had to worry.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn some cases, patients and their families received treatment from more than one non-specialist treating professional who handled the ED inadequately. Also, this may be related to the apparent lack of medical education on EDs in undergraduate studies, which was mentioned by some professionals.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHealth professional 5: \u003cem\u003e\u0026ldquo;There is also the phenomenon that non-specialists take these cases, and the literature says that not only is this not recommended, but it is iatrogenic. It can negatively affect that patient, even if the professional's intention is good.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHealth professional 3: \u003cem\u003e\u0026ldquo;I think that (medical) undergraduate formation is scarce in EDs. What I have seen in undergraduate programs is that, usually, there is a class in the fourth or fifth year on EDs, and that is it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe most relevant facilitators at this intersection were treatment by a multidisciplinary team (41 codes; 62.5% of interviews) and a referral to a specialized ED unit (44 codes; 62.5% of interviews). Moreover, participants highlighted the role of specialists and primary care physicians in the early detection of EDs and timely referral to a specialized multidisciplinary team.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eRelative 2: \u003cem\u003e\u0026ldquo;Thank God she had the chance to receive a multidisciplinary treatment. Not just the dietitian, the psychologist, or the physicians. But all of them working together.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003ePatient 18: \u0026ldquo;I was referred from primary care. I told the doctor that I ate and vomited very often, almost daily. She got worried and referred me here with a psychiatrist.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eHealthcare System\u003c/h2\u003e \u003cp\u003eIn this sample, the Chilean healthcare system was perceived as offering more barriers than facilitators for patients with EDs. The high financial cost of treatment in the private system, which houses most ED specialists in the country, was consistently mentioned as a barrier (104 codes; 77.5% of interviews). This may be explained due to the need for a multidisciplinary team and short intervals between appointments, the lack of reimbursement by insurers, and the high cost of inpatient treatment.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eRelative 1: \u003cem\u003e\u0026ldquo;We are talking about four expensive specialists. Some people simply cannot access (treatment). I am spending around 600,000 pesos* a month.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e*Approximately 650 USD as of January 2024.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatient 22: \u003cem\u003e\u0026ldquo;The cost of this is enormous. I feel hyper-privileged to do it because I couldn\u0026rsquo;t afford it, and my family is paying. My mom is trying to sell the house to help my sister with the cost of this because I\u0026rsquo;ve been hospitalized for two months. It is unthinkable. I don\u0026rsquo;t want to calculate what\u0026rsquo;s coming.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe geographic location of specialized health services is another barrier in the healthcare system (63 codes; 47.5% of interviews). Although this barrier was not mentioned by participants from Santiago, it was extensively brought up by patients from other regions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatient 9: \u003cem\u003e\u0026ldquo;We didn\u0026rsquo;t find many things in the Valpara\u0026iacute;so Region. The only hope we had was Santiago. [...] Where I am (receiving treatment), many people must travel to Santiago. There are no other places to receive all this help.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurthermore, this barrier is linked to another negative aspect of the healthcare system: the lack of specialists (66 codes; 70% of interviews).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatient 6: \u003cem\u003e\u0026ldquo;Not many professionals specialize in these kinds of disorders. It was hard for me to find (a specialist). In fact, I could say that I never found one until I was hospitalized.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHealth professional 4: \u003cem\u003e\u0026ldquo;Most of the specialists work in Santiago, which makes (the situation) more dramatic. These disorders require a degree of specialization, so, primary care teams or even mental health teams in other regions do not have the expertise to handle EDs correctly.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eSocial and Cultural Context\u003c/h2\u003e \u003cp\u003eChilean society has yet to shift toward a culture that adequately recognizes and addresses EDs. Although in recent years there has been greater visibility towards EDs, and this was recognized as a facilitator in several interviews (27 codes; 37.5% of interviews), cultural ignorance and misinformation still exist (80 codes; 80% of interviews).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eRelative 3: \u003cem\u003e\u0026ldquo;They treated us badly as parents because I felt they blamed us. The disease was very unknown. They couldn't understand how we couldn't feed our daughter.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHealth professional 4: \u003cem\u003e\"The nonrecognition shows that there is a lot of ignorance in our society regarding eating disorders.\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eStigma (41 codes; 55% of interviews) and society's positive value of female thinness (29 codes; 40% of interviews) are linked to misinformation. Those factors may perpetuate harmful behaviors and affect access.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatient 2: \u003cem\u003e\u0026ldquo;The social stigma is that you must be thin. In the end, you may know you have an eating disorder, but you don't want to get better because you feel more accepted in society. Nobody is going to judge you if you are skinny or if you fit into social standards.\"\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative research explored facilitators and barriers to access to treatment in patients with EDs in Chile. Interviewing three different groups allowed us to identify factors that affect access to care. Furthermore, it was possible to establish that each group tended to mention more barriers and facilitators specific to their own perspective or field, which was also reported in the study by K\u0026auml;stner et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. For example, patients mostly described ego-syntonic behaviors as barriers, while health professionals emphasized the lack of knowledge or expertise. Meanwhile, the most important facilitators for families were the recognition of EDs and their own involvement in the treatment of their relatives.\u003c/p\u003e \u003cp\u003eInterestingly, each of the five main barriers found in this study represents a different category or intersection of the model proposed in the analysis, reinforcing the idea that the problem must be addressed from different angles. With regards to the five main facilitators, four emphasize the role of families. In EDs, family members play an essential role in the recovery of patients, an aspect that has been emphasized in other qualitative studies [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe barriers and facilitators found in the analysis are relatively similar to those found in other studies, such as the systematic review by Ali et al [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] and the Scoping review by Nicula et al [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The geographic barrier, which did not appear in these but was found in our study, was addressed in three studies from Australia and New Zealand [\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Another barrier found in this study was the existence of a longstanding ED (45% of the interviews). Some data suggest that a prolonged clinical course of the ED may be a consequence of late treatment initiation (40). However, to our knowledge, this is the first study that also considers it as a barrier. A longstanding ED may delay the start of treatment and perpetuate the illness, as the difficulty of seeking help is accentuated due to the ego-syntonic nature of symptoms.\u003c/p\u003e \u003cp\u003eOnly one patient interviewed did not refer to her mother as an important figure in the therapeutic process. She was the sample's oldest patient, and instead, she referred to her husband. This is in accordance with data from the international literature, where fathers are less involved than mothers in treatment [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe average DUED estimated in our study was 7.6 years (median 5.8 years), representing, to our knowledge, the longest time published in the literature on ED. The clinical characteristics of the sample could partially explain this finding since this study included patients with different types of EDs. Most publications have been done in patients with AN. A recent systematic review found that the DUED for AN was 2.5 years, while for BN it was 4.4 years, and for binge-eating disorder 5.6 years [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAfter the studies by K\u0026auml;stner and McNicholas [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], this is the third qualitative publication that explores barriers to treatment for patients with EDs from the perspective of patients, family members, and health professionals. To our knowledge, this is the first study done in a developing country. This may contribute to filling an important gap in the literature since all the studies published to date have been conducted in countries with greater resources.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eMost of the study limitations are due to the small sample size. Although there was theoretical saturation, three variables could not be explored exhaustively (migrant status, indigenous people, and male gender). Patient gender may be important, as men with EDs are often less recognized, less treated, and more stigmatized [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Primary healthcare professionals were not included. Moreover, the health professionals included in the study were mainly ED specialists working in a private clinic, which is uncommon for the Chilean healthcare system. Although few professionals from the public healthcare system were interviewed, the inclusion of specialists mostly from the private system represents the existing gap between the public and private healthcare systems in Chile.\u003c/p\u003e \u003cp\u003eEven though this study includes patients and families from various regions of Chile, it fails to represent the whole country. There is a bias in the patients\u0026rsquo; sample, as they were receiving treatment. The literature shows that patients with EDs, particularly young people, often do not seek treatment and that this \u0026ldquo;untreated\u0026rdquo; group may manifest other barriers [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Second, the sample lacked participants from more extreme regions of the country (such as the Extreme North and Patagonia), which could have further enriched the analysis. Last, there is a significant overrepresentation of patients with private health insurance (68% in the sample versus 16.9% according to official data [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]). Although the high cost of treatment was one of the most relevant barriers in the analysis, the referral processes and the lack of specialists would have had a greater weight if a representative sample of the Chilean public health insurance system had been included.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003ePublic health implications\u003c/h2\u003e \u003cp\u003eSociety is relatively poorly educated about EDs, and public education programs are warranted. There is also a lack of education among health professionals in recognizing symptoms and risk factors of ED that delay diagnosis. Interventions at both levels may be a cornerstone for a public health intervention.\u003c/p\u003e \u003cp\u003eEarly treatment in EDs is important, considering the early onset age and the neurobiological consequences over time [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Some population-level interventions have shown promising results. In England, FREED (First Episode Rapid Early Intervention) is an evidence-based early intervention model for EDs focused on people aged 16 to 25. It has successfully reduced waiting lists, DUED, and clinical outcomes [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. It has been implemented in 80% of NHS services for adults [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. FREED has been modified for use in Australia, where Australian Medicare funds treatment up to 40 therapy sessions and 20 dietitian appointments per year, but with a focus on severe ED [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. In contrast, a German program that sought to reduce the DUED of EDs with a systemic public health intervention, including school activities, failed to show statistical significance, probably due to methodological issues [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCost-effectiveness in developing interventions to prevent and treat EDs has been described when public health systems are involved. An example of this is the English FREED model for intensive treatment of EDs where 4.472 pounds were saved per patient [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. In Germany, savings of 2 to 4 euros were estimated per euro invested in AN, and 4 euros saved per euro invested in BN [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. It must be emphasized that in both countries, the public health system is superior to Chile's.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eFuture research\u003c/h2\u003e \u003cp\u003eWe suggest conducting more studies on access to treatment for patients with EDs in developing countries. In the long run, low visibility affects the development of public health policies, the physical and mental health of patients, and the perpetuation of stigma.\u003c/p\u003e \u003cp\u003eMoreover, it would be useful to encourage epidemiological studies on EDs in Latin America to favor the visibility of the problem and decision-making. Likewise, it would be worthwhile to inquire more into patients' experiences within the public system, male patients\u0026rsquo; experiences, and stratifying by sexual orientation and ethnic groups.\u003c/p\u003e \u003cp\u003ePreviously, we acknowledged that this study didn\u0026rsquo;t include individuals with EDs who have not accessed specialist care. However, this would be a key point for future studies regarding access to treatment in developing countries like Chile. Furthermore, individuals diagnosed with an ED in primary care who never entered specialist treatment could be a key target group for understanding barriers and developing public policies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides qualitative information regarding access to treatment for EDs in Chile. It is the first study of its kind done in a developing country. This may favor the understanding of the phenomenon as a global problem.\u003c/p\u003e \u003cp\u003eWhen dealing with EDs, the entire family unit is distressed. Interventions and proposals should be aimed at modifying family dynamics inside and outside health care to facilitate rapid identification. Likewise, the effect of the barriers inherent to the healthcare system and the inadequate training of professionals should be considered. Finally, it is necessary to reduce DUED to avoid worse clinical outcomes and chronicity of the disorder.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAN: Anorexia nervosa.\u003c/p\u003e\n\u003cp\u003eARFID: Avoidant/restrictive food intake disorder.\u003c/p\u003e\n\u003cp\u003eBMI: Body-Mass-Index.\u003c/p\u003e\n\u003cp\u003eBN: Bulimia nervosa.\u003c/p\u003e\n\u003cp\u003eDSM-5: Diagnostic and Statistic Manual of Mental Disorders \u0026ndash; Fifth Edition.\u003c/p\u003e\n\u003cp\u003eDUED: Duration of untreated eating disorder.\u003c/p\u003e\n\u003cp\u003eED: Eating disorder.\u003c/p\u003e\n\u003cp\u003eEDs: Eating disorders.\u003c/p\u003e\n\u003cp\u003eFSE: Family and social environment.\u003c/p\u003e\n\u003cp\u003eHCS: Healthcare system.\u003c/p\u003e\n\u003cp\u003eHP: Health professionals\u003c/p\u003e\n\u003cp\u003eOSFED: Other specified feeding or eating disorder.\u003c/p\u003e\n\u003cp\u003eP: Patient.\u003c/p\u003e\n\u003cp\u003eSCC: Social and cultural context.\u003c/p\u003e\n\u003cp\u003eUFED: Unspecified feeding or eating disorder.\u003c/p\u003e\n\u003cp\u003eUSD: United States Dollar.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was obtained from\u0026nbsp;the Scientific Ethics Committee of both the Pontificia Universidad Cat\u0026oacute;lica de Chile (ID: 221024003) and the Southeast Metropolitan Health Service in Santiago. Additionally, before starting recruitment, we obtained authorization from the medical management of the San Carlos de Apoquindo Clinic and the Dr. S\u0026oacute;tero del R\u0026iacute;o Hospital. All participants and, in the case of minor participants, legal guardians provided written informed consent before study inclusion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEvery quotation in this publication was obtained prior consent from the respective participant, and in the case of minor participants, from their legal guardians. The anonymity of the data was preserved.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe anonymized interview transcripts will be made available by the authors upon legitimate request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFC was the leading investigator, designing the study, conducting the interviews, and analyzing the datasets. JC was the thesis\u0026rsquo;s advisor, designing the methods, reviewing and editing the text. RJ was the thesis\u0026rsquo;s coadvisor, participating in the design, coordinating the data collection, and giving feedback for the drafts. FR transcribed interviews, wrote part of the results and discussion, and worked on the final manuscript. PU, MV, MEG, VI, JA, MAD and DC participated in the writing, reviewing and editing process. PK transcribed interviews and worked on the final manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe give special thanks to Jaime Cerda, who was the leading advisor of the thesis, and Melina Vogel, who gave the support of the ED Unit at UC-Christus for this work. Additionally, we would like to thank everyone who helped while developing the study. Alphabetically ordered, they are: \u0026Aacute;ngela Cruzat, Catalina Cotroneo, Gabriela Espinoza, Karina Husak, Mar\u0026iacute;a Elena Gumucio, Mar\u0026iacute;a Jos\u0026eacute; Silva, and Pascuala Urrejola.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHouse J, Schmidt U, Craig M, Landau S, Simic M, Nicholls D, et al. Comparison of specialist and nonspecialist care pathways for adolescents with anorexia nervosa and related eating disorders. International Journal of Eating Disorders 2012;45:949\u0026ndash;56.\u003c/li\u003e\n\u003cli\u003eBEAT. The costs of eating disorders: Social, health and economic impacts. London: 2015.\u003c/li\u003e\n\u003cli\u003eTreasure J, Duarte TA, Schmidt U. Eating disorders. The Lancet 2020;395:899\u0026ndash;911.\u003c/li\u003e\n\u003cli\u003eRose KL, Negrete CE, Sellinger G, Chang T, Sonneville KR. Adolescent and emerging adult perceptions of eating disorder severity and stigma. International Journal of Eating Disorders 2022;55:1296\u0026ndash;304.\u003c/li\u003e\n\u003cli\u003eNational Institute for Health and Care Excellence. Eating Disorders: recognition and treatment. London: 2017.\u003c/li\u003e\n\u003cli\u003eBurt A, Mannan H, Touyz S, Hay P. Prevalence of DSM-5 diagnostic threshold eating disorders and features amongst Aboriginal and Torres Strait islander peoples (First Australians). BMC Psychiatry 2020;20:449.\u003c/li\u003e\n\u003cli\u003eAustin A, Flynn M, Richards K, Hodsoll J, Duarte TA, Robinson P, et al. Duration of untreated eating disorder and relationship to outcomes: A systematic review of the literature. European Eating Disorders Review 2021;29:329\u0026ndash;45.\u003c/li\u003e\n\u003cli\u003eNicula M, Pellegrini D, Grennan L, Bhatnagar N, McVey G, Couturier J. Help-seeking attitudes and behaviours among youth with eating disorders: a scoping review. 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International Journal for Quality in Health Care 2007:19(6):349-357.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien B, Harris I, Beckman T, Reed D, Cook D. Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Academic Medicine 2014: 89(9):1245-1251.\u003c/li\u003e\n\u003cli\u003eKjellsson G, Clarke P, Gerdtham U-G. Forgetting to remember or remembering to forget: A study of the recall period length in health care survey questions. J Health Econ 2014;35:34\u0026ndash;46.\u003c/li\u003e\n\u003cli\u003eK\u0026auml;stner D, Buchholz I, Weigel A, Brunner R, Voderholzer U, Gumz A, et al. Facilitators and barriers in anorexia nervosa treatment initiation (FABIANA): study protocol for a mixed-methods and multicentre study. BJPsych Open 2019;5:e92.\u003c/li\u003e\n\u003cli\u003eCoelho JS, Suen J, Marshall S, Burns A, Lam P-Y, Geller J. Parental experiences with their child\u0026rsquo;s eating disorder treatment journey. J Eat Disord 2021;9:92. \u003c/li\u003e\n\u003cli\u003eWacker EC. Barriers and facilitators to seeking treatment for subclinical eating disorders: The importance of supportive relationships. J Fam Psychother 2018;29:292\u0026ndash;317.\u003c/li\u003e\n\u003cli\u003eCiao AC, Lebow J, VandenLangenberg E, Ohls O, Berg KC. A qualitative examination of adolescent and parent perspectives on early identification and early response to eating disorders. Eat Disord 2022;30:249\u0026ndash;66.\u003c/li\u003e\n\u003cli\u003eAli K, Fassnacht DB, Farrer L, Rieger E, Feldhege J, Moessner M, et al. What prevents young adults from seeking help? Barriers toward help‐seeking for eating disorder symptomatology. International Journal of Eating Disorders.\u003c/li\u003e\n\u003cli\u003eClark MTR, Manuel J, Lacey C, Pitama S, Cunningham R, Jordan J. Reimagining eating disorder spaces: a qualitative study exploring Māori experiences of accessing treatment for eating disorders in Aotearoa New Zealand. J Eat Disord 2023;11:22.\u003c/li\u003e\n\u003cli\u003eLiu L, Hay P, Conti J. Perspectives on barriers to treatment engagement of people with eating disorder symptoms who have not undergone treatment: a qualitative study. BMC Psychiatry 2022;22:239.\u003c/li\u003e\n\u003cli\u003eLinardon J, Rosato J, Messer M. Break Binge Eating: Reach, engagement, and user profile of an Internet‐based psychoeducational and self‐help platform for eating disorders. International Journal of Eating Disorders 2020;53:1719\u0026ndash;28.\u003c/li\u003e\n\u003cli\u003ePi\u0026ntilde;ar-Guti\u0026eacute;rrez, A., Dios-Fuentes, E., Rem\u0026oacute;n-Ruiz, P. \u003cem\u003eet al.\u003c/em\u003e Description of characteristics and outcomes of a cohort of patients with severe and enduring eating disorders (SE-ED). J Eat Disord 2021;9:135.\u003c/li\u003e\n\u003cli\u003eGanson KT, Hamilton-Mason J. Not \u0026ldquo;My Territory:\u0026rdquo; How Gender Role Socialization Impacts Father Involvement in Caring for a Child with an Eating Disorder. Smith Coll Stud Soc Work 2019;89:18\u0026ndash;37.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Sullivan HM. The influence of gender on paternal involvement in the treatment process of a child or adolescent with an eating disorder. MRes Thesis. University College Cork, 2022.\u003c/li\u003e\n\u003cli\u003eMcNicholas F, O\u0026rsquo;Connor C, McNamara N, O\u0026rsquo;Hara L. Eating disorder services for young people in Ireland: perspectives of service providers, service users and the general adolescent population. Ir J Psychol Med 2018;35:301\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eDearden A, Mulgrew KE. Service Provision for Men with Eating Issues in Australia: An Analysis of Organisations\u0026rsquo;, Practitioners\u0026rsquo;, and Men\u0026rsquo;s Experiences. Australian Social Work 2013;66:590\u0026ndash;606.\u003c/li\u003e\n\u003cli\u003eTrompeter N, Bussey K, Forbes MK, Mond J, Hay P, Basten C, et al. Differences between Australian adolescents with eating disorder symptoms who are in treatment or not in treatment for an eating disorder. Early Interv Psychiatry 2021;15:882\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eDepartamento de Estudios y Desarrollo. Análisis Estadístico del Sistema Isapre con Perspectiva de Género. 2021. \u003c/li\u003e\n\u003cli\u003eAllen KL, Mountford VA, Elwyn R, Flynn M, Fursland A, Obeid N, et al. A framework for conceptualising early intervention for eating disorders. European Eating Disorders Review 2023;31:320\u0026ndash;34.\u003c/li\u003e\n\u003cli\u003eFlynn M, Austin A, Lang K, Allen K, Bassi R, Brady G, et al. Assessing the impact of First Episode Rapid Early Intervention for Eating Disorders on duration of untreated eating disorder: A multi‐centre quasi‐experimental study. European Eating Disorders Review 2021;29:458\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eAustin A, Flynn M, Shearer J, Long M, Allen K, Mountford VA, et al. The First Episode Rapid Early Intervention for Eating Disorders ‐ Upscaled study: Clinical outcomes. Early Interv Psychiatry 2022;16:97\u0026ndash;105\u003c/li\u003e\n\u003cli\u003eRichards KL, Hyam L, Allen KL, Glennon D, Di Clemente G, Semple A, et al. National roll‐out of early intervention for eating disorders: Process and clinical outcomes from first episode rapid early intervention for eating disorders. Early Interv Psychiatry 2023;17:202\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eWade T, Pennesi J-L, Zhou Y. Ascertaining an efficient eligibility cut-off for extended Medicare items for eating disorders. Australasian Psychiatry 2021;29:519\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eGumz A, Weigel A, Wegscheider K, Romer G, L\u0026ouml;we B. The psychenet public health intervention for anorexia nervosa: a pre\u0026ndash;post-evaluation study in a female patient sample. Prim Health Care Res Dev 2018;19:42\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eBode K, G\u0026ouml;tz von Olenhusen NM, Wunsch E-M, Kliem S, Kr\u0026ouml;ger C. Population-based cost-offset analyses for disorder-specific treatment of anorexia nervosa and bulimia nervosa in Germany. International Journal of Eating Disorders 2017;50:239\u0026ndash;49.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Eating disorders, access to treatment, early intervention, public health, Chile","lastPublishedDoi":"10.21203/rs.3.rs-3909214/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3909214/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEating disorders (EDs) are associated with high morbidity and mortality, affecting predominantly young people and women. A delay in starting treatment is associated with chronic and more severe clinical courses; however, evidence on barriers and facilitators of access to care in Latin America is scarce. We aimed to identify barriers and facilitators of ED treatment in Chile from the perspective of patients, relatives, and health professionals.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eQualitative approach through semi-structured interviews with patients, their relatives, and health professionals. Participants were recruited from two ED centers in Santiago, Chile (one public and one private). Analysis was mainly based on Grounded Theory, using MAXQDA software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e40 interviews were conducted (n\u0026thinsp;=\u0026thinsp;22 patients, 10 relatives, and 8 health professionals). The mean age of patients was 21.8 years, while the mean duration of untreated ED was 91.4 months (median 70 months). Five categories emerged with intersections between them: patient (P), family and social environment (FSE), health professionals (HP), healthcare system (HCS), and social and cultural context (SCC). Relevant barriers appeared within these categories and their intersections, highlighting a lack of professional knowledge or expertise, cultural ignorance or misinformation regarding EDs, and patient's ego-syntonic behaviors. The main facilitators were patients\u0026rsquo; and relatives\u0026rsquo; psychoeducation, recognition of symptoms by family members, and parents taking the initiative to seek treatment.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study provides information regarding access to treatment for patients living with EDs in Chile. A practical public health approach should consider the multi-causality of delay in treatment and promoting early interventions.\u003c/p\u003e","manuscriptTitle":"Exploration of Barriers to Treatment for Patients with Eating Disorders in Chile","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-02 15:16:18","doi":"10.21203/rs.3.rs-3909214/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-30T12:39:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-28T21:16:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99374257607632396816783505467008194747","date":"2024-05-05T20:27:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-05T01:06:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"064f85e9-676a-48de-88b6-10079f653a7f","date":"2024-02-13T16:08:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-13T15:12:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-02T02:21:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-31T13:45:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Eating Disorders","date":"2024-01-29T16:07:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"543599f2-5d5f-411f-be31-f9c32a4833e0","owner":[],"postedDate":"February 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-14T16:05:14+00:00","versionOfRecord":{"articleIdentity":"rs-3909214","link":"https://doi.org/10.1186/s40337-024-01104-x","journal":{"identity":"journal-of-eating-disorders","isVorOnly":false,"title":"Journal of Eating Disorders"},"publishedOn":"2024-10-12 15:57:34","publishedOnDateReadable":"October 12th, 2024"},"versionCreatedAt":"2024-02-02 15:16:18","video":"","vorDoi":"10.1186/s40337-024-01104-x","vorDoiUrl":"https://doi.org/10.1186/s40337-024-01104-x","workflowStages":[]},"version":"v1","identity":"rs-3909214","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3909214","identity":"rs-3909214","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}