Examining perceptions of anorexia nervosa: Should people with anorexia nervosa receive health-related welfare benefits?

(80%)


Background
Anorexia nervosa (AN) is a type of eating disorder (ED) and mental illness characterised by significantly low body weight or rapid weight loss due to behaviours intended to reduce calorie intake (World Health Organization [WHO], 2020).Complications of AN can include tiredness, weakness, musculoskeletal problems, cardiac abnormalities, and difficulties with memory and concentration (National Health Service [NHS], 2021).Subsequently, the UK's leading ED charity Beat (2017) reports that AN can have huge adverse effects on sufferers' day-to-day lives and compromise all aspects of their wellbeing.
Despite this, EDs are often viewed as conscious choices and sufferers believed to be vain and attention-seeking (Beat, 2021b).These perceptions can be highly damaging; stigma against people with mental health issues can negatively impact their self-esteem and social relationships, as well as creating barriers to the provision and take-up of effective structural support (WHO, 2021).Consequently, many people with mental illnesses perceive the associated stigma and subsequent discrimination as equally or more distressing than the symptoms themselves (Time to Change [TTC], 2021b).
In the UK, one form of structural support is Personal Independence Payment (PIP), designed to support people with long-term illnesses and disabilities in meeting additional costs arising from their conditions.Application for this benefit is available to working-age citizens who have a condition expected to compromise their ability to perform day-to-day tasks for at least nine months (HM Government, n.d.).PIP is recognised as having a vital role in helping people with such conditions achieve good quality of life (Disability Benefits Consortium, 2017).However, poverty charity Turn2us (2020) found substantial evidence of negative attitudes towards benefits claimants, who are subject to widespread societal judgement of how supposedly deserving they are of this support.

Aim
AN appears to be subject to societal misperceptions and stigma, which can have huge negative impacts on sufferers' lives.As stigma is known to be a barrier to structural support for mental illness, the aim of this research was to investigate whether people with AN are generally deemed deserving of PIP, and how stigma and perceptions of personal choice may affect this.
Prior to specifying research questions, a review of existing literature on both ED stigma and welfare benefits was conducted to establish what is known about both topics, as well as the documented interaction between them.

Attitudes towards EDs
Multiple previous studies have found evidence of both AN and EDs more generally being subject to substantially negative attitudes.For instance, in a study of American undergraduates by Mond et al. (2006), 72% of respondents said they would find the behaviour of somebody with AN irritating, and 54% thought that someone with AN was vain.Additionally, 64% expressed that they would be doubtful or unwilling to interview someone with AN for a job, thus demonstrating how perceptions of the condition can impact other areas of sufferers' lives.
Similarly, Katterman and Klump (2010) found that their American undergraduate sample viewed EDs more negatively than other mental illnesses including obsessive compulsive disorder, schizophrenia and depression.Overall, respondents believed 63% of people with EDs conformed to negative stereotypes including being vain, selfindulgent and having a self-inflicted condition.Such perceptions were also observed by Geerling and Saunders (2015), who found that a character with AN was considered vainer than one with major depressive disorder.Additionally, the AN sufferer was regarded as more to blame for their condition, which led to respondents experiencing anger towards the sufferer.

Volitional stigma
Perceptions of personal choice and control appear prevalent in attitudes towards EDs, and Easter (2012) coined the term 'volitional stigma ' (p. 1409) to refer to attitudes that position the conditions as lifestyle choices rather than illnesses.From a sample of 50 American women with EDs, Easter found that 88% had experienced volitional stigma, which participants widely believed to encourage negative stereotypes of ED sufferers as vain and selfish.
Multiple empirical studies analysing attitudes of the general population have also observed volitional stigma.For instance, from two studies of over 1,600 British adults, Crisp (2005) found that one third (33-34%) considered sufferers to blame for their condition, with 35-38% believing that someone with an ED 'could pull themselves together' (Crisp, 2005, p. 151).A more recent German study by Angermeyer et al. (2013) resulted in similar findings, with 31% of respondents considering someone with AN to be weak-willed and therefore responsible for their condition.

Stigma and attitudes to support for AN
Identifying that EDs appear subject to a form of stigma distinct from that of other mental illnesses, Crisafulli et al. (2010) formulated the Eating Disorder Stigma Scale (EDSS) to capture this, measuring perceptions of sufferers on four subscales: Trivial, Selfish/Vain, Weak, and Blame.Their quantitative study analysed the impacts of different etiological explanations for AN on attitudes towards the condition and support for better medical insurance for sufferers.The research found that respondents given a biological explanation of AN had both the lowest overall stigma and the highest willingness to sign a petition for better insurance.Therefore, this suggests that greater levels of AN stigma may correspond with lower endorsement of support for sufferers.
A similar study on attitudes to AN was conducted by Bannatyne and Abel (2015), also using measures of the EDSS and willingness to sign a petition.Their findings mirrored those of Crisafulli et al. (2010) in that a biological explanation elicited both the lowest levels of stigma and the most support for better insurance.However, a multifactorial explanation provoked the most stigma, but these respondents had significantly higher willingness to sign than those given a sociocultural explanation, demonstrating that greater AN stigma does not inevitably align with less inclination to help those with the condition.However, as neither this study nor that of Crisafulli et al. (2010) measured the direct interaction between AN stigma and advocacy for formal provision for sufferers, further research into this relationship would be beneficial.Moreover, these studies referenced medical insurance rather than welfare benefits, which may be viewed differently due to recipients' abilities to spend the money on goods and services not directly related to their condition (Fang & Huber, 2020).

Benefits deservingness
van Oorschot (2000) identified that perceptions of deservingness originating from historic Poor Laws appear salient in contemporary attitudes towards social welfare claimants.He suggested five key principles commonly used to determine claimants' deservingness, which have since become known as the '"CARIN" criteria' (van Oorschot & Roosma, 2017, p.13).These are: Control (people seen to have less power over their condition are viewed as more deserving); Attitude (claimants viewed as more grateful are perceived as more deserving); Reciprocity (people earn assistance by paying into the system); Identity (claimants are perceived as more deserving if they share characteristics with the person(s) making the judgement); Need (people with greater requirement of help are viewed as more deserving).Though Attitude was not analysed, the initial investigation by van Oorschot (2000) did find significant support for all other criteria in a representative sample of the Dutch population.The strongest support was for Control, followed by Identity, Reciprocity, and Need.
The utility of the CARIN criteria is widely acknowledged across deservingness literature (Bonoli, 2021;De Tavernier & Draulans, 2021), having been substantiated by many empirical studies (e.g., Heuer & Zimmermann, 2020;Meuleman et al., 2020).However, the role of the framework in deservingness of disability and sickness benefits claimants specifically appears underexplored, as there is a general conception of this type of welfare recipient largely being considered more deserving than others (Böheim & Leoni, 2018).Indeed, from a series of studies across Denmark, the United States and Japan, Jensen and Petersen (2017) found that people who were sick were deemed more deserving of government aid than those who were unemployed.Thus, the authors suggested that these recipients are not subject to the same scrutiny as other types of claimants.However, in one of their Danish studies, perceived deservingness of government-funded healthcare was significantly reduced when respondents believed a person's condition to be caused by controllable choices such as smoking.This suggests that the Control aspect of CARIN may play still a role within this category.
Similarly, Laenen et al. (2019) found support for Control in a British focus group study, where some participants believed that personal control over ill health was justification for withholding welfare payments or healthcare, for example, viewing somebody with unhealthy eating habits as undeserving of support.

Condition-specific deservingness
Supposed deservingness of government assistance has also been found to vary according to specific diagnoses.In an online forum study by Dumit (2006), the Control element of CARIN appeared intertwined with the perceived authenticity of a condition.Chronic fatigue syndrome (CFS) and multiple chemical sensitivity (MCS) were classified as 'contested illnesses' (Dumit, 2006, p. 578), often having their existence disputed by medical professionals and the public due to fluctuating, invisible symptoms and uncertain causes.The study found that people with CFS and MCS were frequently denied welfare payments due to professionals supposedly doubting the legitimacy of their claims.Sufferers reported scepticism, with one participant being told to 'pull herself together' (Dumit, 2006, p. 582).This echoes findings of Crisp (2005) in relation to AN.Though no studies appear to have explored public perceptions of AN in relation to welfare benefits, AN has been considered a contested illness (Giles, 2006), so it is plausible that investigation into the perceived benefits deservingness of AN would lead to findings similar to Dumit's.
Other qualitative studies have also found visibility of illness to be a prominent factor in deservingness decisions.Interviewing disability policy-makers across Australia and Canada, McAllister (2020) found clear divisions between welfare candidates deemed ideal and non-ideal.Ideal claimants had conditions that were visible, medically diagnosed and uncontrollable.
Consequently, many participants stated that physical illnesses were ideal and mental were non-ideal, and a notable bias emerged against less visible and verifiable conditions.
Geiger (2021) highlighted a paucity in research into the benefits deservingness of specific health conditions, which he subsequently investigated.Findings from large-scale studies across 10 countries suggested that conditions considered more severe were viewed as more deserving of benefits, regardless of the level of individual responsibility ascribed to them or whether they were mental or physical illnesses.However, when mental and physical conditions were deemed similarly serious, mental illnesses were generally viewed as less deserving.This does not support the Control aspect of CARIN and highlights that the classification of mental illness does not automatically translate to low perceived deservingness.Multiple factors appear to contribute, and illnesses with the same broad classification may be judged differently.These results indicate a significant need for further research to build upon Geiger's initial investigation.

Research questions
Overall, findings from the reviewed literature suggest that stigma towards EDs -specifically AN -is prevalent across the Western world, with sufferers often viewed as vain and selfish.Volitional stigma was a prominent theme, and many studies found evidence of AN being perceived as a personal choice and sufferers blamed for their condition.
Welfare benefits literature indicates that conditions seen as more controllable are generally viewed as less deserving.Additionally, mental health conditions are often viewed as less deserving than physical ones.However, there appears a notable gap in knowledge of perceived deservingness of specific conditions, and no studies appear to directly link attitudes towards AN with perceived benefits deservingness.Therefore, this research aimed to begin to fill these gaps, using the following research questions (RQs): RQ1: Do students typically believe that people with AN should be eligible to apply for PIP?
Literature indicates AN is associated with multiple characteristics believed to reduce perceived deservingness of government assistance -primarily personal control and classification of mental illness.However, the uncertain status of AN as a contested illness may influence attitudes to PIP.As AN has both physical and mental symptoms it may not fit solely in the category of either physical or mental illness.This first question aimed to quantify support for PIP for AN within the sample, which could be addressed in further detail by subsequent research questions.

RQ2: Does AN stigma affect students' agreement that people with AN should be eligible to apply for PIP?
Higher levels of stigma may be associated with less advocacy of structural support for sufferers.However, this is not consistent across literature, and existing research relates to health insurance rather than benefits.Therefore, investigation is needed into how stigma may relate to attitudes towards sickness/disability benefits for people with AN.

RQ3: Does the belief that AN is a choice affect students' agreement that people with AN should be eligible to apply for PIP?
Volitional stigma was prominent in the literature review; this could link to the Control aspect of CARIN, which has been widely supported as a factor in welfare deservingness decisions.Therefore, this research question aimed to assess the specific role that perceptions of AN being a choice may have in determinations of benefits deservingness.

Methodology
This research utilised the quantitative approach, which involves collecting and analysing measurable data to find relationships between variables (Creswell & Creswell, 2018).Quantitative methods are useful for gaining an overview of opinions (Black, 1999;Ruane, 2016) and allow subjective beliefs to be converted to objective, numerical forms for analysis (Bhaskar, 2016;Grønmo, 2019).Additionally, quantitative methodology can be replicated in future studies, allowing for comparisons between results and for procedures to be validated through repetition (Morgan, 2014).

Research design
Data was collected via an online questionnaire (see Appendix A), created and administered on the Qualtrics platform, Version March 2021.This method was chosen due to its time and cost efficiency (Vehovar & Manfreda, 2017), and its increased sense of privacy and anonymity in comparison to paper-based surveys, thus promoting honest answers (Beins & McCarthy, 2018).Prior to administration, the questionnaire was piloted by the researcher and two members of university staff to test its length and identify areas for improvement (Babbie, 2021).
The final questionnaire contained nine questions, some of which were split into sub-questions.Most survey items were closed-ended, fixed response questions, chosen to maximise chances of questionnaire completion (Ruane, 2016) and eliminate misinterpretation of answers by the researcher (Walliman, 2018).Explanations of both AN and PIP were provided to ensure all respondents had the same basic understanding of these terms, with descriptions obtained from academically respected sources (HM Government, n.d.;NHS, 2021;WHO, 2020) to minimise bias.
An adapted version of the validated EDSS (Crisafulli et al., 2010) was used, containing eight of the original 20 items.The EDSS was condensed to reduce the length of the total survey, as well as to eliminate perceived repetition of questions, as some of the original items had only subtle differences between them.(For example, 'they are selfish' vs. 'they only care about themselves' (Crisafulli et al., 2010, p. 764)).However, all four original subscales (Trivial, Selfish/Vain, Weak, and Blame) were retained, with two items chosen from each to maintain a balance of each element of stigma.
Each chosen item contained a statement reflecting a distinct stigmatising view of AN (see Appendix A, Question 5 for full list).Respondents rated agreement with each statement on a 5-point Likert scale (Likert, 1932) (5 = strongly agree).The mean score of all items is referred to as overall stigma, as per the original EDSS.
As the scale has previously demonstrated that it measures the intended concept, its use increases the validity of results (Kazi & Khalid, 2012).Since its inception, the EDSS has been used in both full and adapted variants and has demonstrated Cronbach's alpha values between 0.81 and 0.95 (Bannatyne & Abel, 2015;Bannatyne & Stapleton, 2015), showing excellent internal consistency -a measure of reliability (Field, 2013).Utilising the EDSS allows for direct comparisons between this research and other studies that have used the scale.

Sampling
This research targeted undergraduate students in the School of Human and Health Sciences at the University of Huddersfield, who were recruited through circulation of two invitation emails.The sampling was purposive, as evidence shows that prevalence and risk of EDs are particularly high among university-age individuals (Lipson & Sonneville, 2017;Ward et al., 2019), and therefore the views of this group were considered particularly relevant.Furthermore, multiple reviewed studies were conducted with university samples (e.g., Bannatyne & Abel, 2015;Crisafulli et al., 2010;Geerling & Saunders, 2015), allowing for direct comparisons between findings.However, individuals with history of an ED were excluded as they may have held biased views about AN (Crisafulli et al., 2008).

Ethics
Prior to any data collection, this study received full ethical clearance from the University of Huddersfield Ethics Committee (Division of Criminology, Politics and Sociology).Ethical guidelines of both the University of Huddersfield (2019) and the British Sociological Association (2017) were consulted and adhered to throughout the project, following the overarching principles of honesty, integrity, safety and confidentiality.
All respondents provided informed consent before progressing to the survey, which was clearly conveyed as voluntary, and respondents were notified about their right to withdraw without penalty.It was clearly communicated that respondents would not be personally identifiable from the data they shared, and an anonymous ID number was generated for all for the purpose of withdrawal.To allow respondents control over disclosure of personal information, a prefer not to say option was provided wherever possible.
In addition to minimising bias, another reason for excluding individuals with EDs was that they may be considered vulnerable due to the status of EDs as serious mental health conditions (NHS, 2021).As it was recognised that EDs can be distressing subject matter, information about relevant support services was made available to respondents both before and after the questionnaire, including to those excluded.This included contact details for university wellbeing services, as well as those for ED charity Beat and mental health charity Mind.

Data analysis
The survey yielded 30 responses.However, seven respondents divulged personal history of an ED and were therefore excluded, leaving a sample size of 23.Data was exported from Qualtrics into SPSS Version 26.0 for Windows.Prior to substantive analysis, several tests were run to ensure the reliability and validity of the data.Cronbach's alpha for the adapted EDSS was calculated as 0.916, demonstrating excellent internal consistency (Field, 2013).Histograms and Shapiro-Wilk tests showed the data was not normally distributed and therefore non-parametric tests were used for analysis, as they are more versatile than parametric equivalents and do not rely on data falling within a certain range (Abu-Bader, 2021; Bathke et al., 2008).In subsequent inferential statistical tests, the statistical significance level of 0.05 was used, as is the industry standard (Wagner, 2013).Percentage figures were rounded to two decimal places.

Findings Demographics
Demographic information was collected from respondents to enable recognition of patterns and detect any potential bias from over-representation of certain characteristics (Hughes et al., 2016).It was subsequently identified that the sample was predominantly female (87%), therefore, further data analysis was performed on responses from females only (n = 20), as the number of non-female respondents was not high enough to detect meaningful differences between genders (Blann, 2018).Within this final sample, the modal age was 18-24 years (75%), followed by 25-34 years (20%), and 45-54 years (5%).

Eligibility for PIP
RQ1 asked: Do students typically believe that people with AN should be eligible to apply for PIP?
Figure 1 illustrates the percentage of respondents that answered yes to the question 'Do you believe that people with AN should be eligible to apply for PIP?'.

Figure 1
Belief that someone with AN should be eligible to apply for PIP The majority of respondents (80%) believed that people with AN should be eligible to apply for PIP, thus answering RQ1.
To examine this finding, variables that may have contributed to respondents' agreement with PIP were explored.Respondents recognised that AN could be a long-term condition, with all selecting an expected average duration of at least one to two years, with the modal response of three to five years (42.1%), and the second most common of >10 years (31.6%).However, cross-tabulation detected no apparent connection between anticipated duration of AN and attitudes to PIP.
Respondents were also asked to classify AN, selecting as many as applicable from 'mental illness', 'physical illness', 'disability', and 'choice'.The results are presented in Table 1.Notably, many of these responses overlapped, which speaks to the general ambiguity around the nature of AN.
All classification labels were cross-tabulated with agreement for PIP, and Pearson's chi-square tests of association were conducted.Results showed that only the association for physical illness was statistically significant (Pearson's chi-square = 4.821, df = 1, p = .028).Following this result, the cross-tabulation of physical illness and agreement for PIP is presented in Table 2.

Table 2
Cross-tabulation of classification of physical illness and agreement for PIP Table 2 shows that most respondents who believed that AN was a physical illness agreed that people with AN should be eligible to apply for PIP (92.9%).This indicates that respondents may have associated PIP with difficulties induced by physical illness, though the questionnaire's description of PIP made no reference to type of health condition required for eligibility.

Effect of stigma on PIP eligibility
RQ2 asked: Does AN stigma affect students' agreement that people with AN should be eligible to apply for PIP?
Figure 2 shows the distribution of overall stigma scores.

Figure 2
Overall stigma scores across the sample Results show that most respondents (95%) had overall stigma scores of below the scale midpoint of 3.00, indicating that overall attitudes towards AN were not substantially stigmatising.Additionally, the modal score was 1.00 (45%) -the lowest possible value -revealing that many respondents did not report any stigmatising beliefs about AN.
The mean values of overall stigma and each EDSS subscale are reported in Table 3.

Table 3
Mean values for overall stigma and EDSS subscales across the sample Table 3 shows low overall stigma (M = 1.41,SD = 0.60).The subscale that elicited the highest score was Blame (M = 1.68,SD = 0.99), indicating this to be the most prominent aspect of stigma.
To address RQ2, overall stigma values were crosstabulated with PIP.There was a clear split in overall stigma scores occurring at 1.50, as most respondents answering yes to PIP (75.1%) had scores that fell below this, whereas most respondents answering no (75%) had scores of 1.50 or higher.This demonstrates that respondents who disagreed with PIP tended to hold higher levels of stigmatising beliefs towards AN.A Mann-Whitney U test was subsequently conducted to analyse the difference between overall stigma scores for respondents answering yes and no for PIP.Table 4 shows the mean rank of overall stigma of respondents that answered yes to PIP (9.34) is substantially lower than the mean rank of respondents that answered no (15.13).This strengthens the finding that overall, those who answered yes held fewer stigmatising beliefs.However, this was not a statistically significant difference (U = 13.500,p = .080).
Table 5 shows differences in levels of disagreement with individual EDSS items between those who answered yes and no to PIP.This allows trends to be observed in which statements were most frequently endorsed and thus contributed to higher overall stigma scores.The choices of 'strongly' and 'somewhat' disagree/agree were collapsed so that responses fell into three categories.
In addition to observed differences in overall stigma scores, Table 5 shows that respondents that answered yes to PIP generally had higher levels of disagreement with individual EDSS items than those who answered no.The biggest differences were observed for statements of a person with AN causing their condition (yes = 93.8%,no = 50%) and being responsible for the condition (yes = 75.1%,no = 50%).Both groups entirely disagreed (100%) with the statement that people with AN only care about looking good.Respondents that answered yes to PIP only showed lower disagreement for the statement that someone with AN is weak (yes = 93.8%,no = 100%).
Considering these findings, in this study stigma did appear to affect students' agreement that people with AN should be eligible to apply for PIP.Though the Mann-Whitney test did not yield statistically significant results, there was a clear relation between higher stigma and disagreement with PIP.Respondents that disagreed with PIP for AN regularly showed higher endorsement of stigmatising statements about AN and generally had higher overall stigma scores.

Perceptions of choice and PIP eligibility
RQ3 asked: Does the belief that AN is a choice affect students' agreement that people with AN should be eligible to apply for PIP?
Table 6 presents disagreement with the statement 'a person with AN can choose to stop their behaviour if they want to', as well as crosstabulation with how respondents answered the PIP question.Levels of agreement were collapsed into three categories: disagree, neutral, and agree.

Table 6
Cross-tabulation of agreement with PIP and agreement with the statement 'a person with AN can choose to stop their behaviour if they want to' Most respondents (80%) disagreed with the statement, however, more respondents agreed (15%) than were neutral (5%).Though this split is very similar to the divide between 'yes' and 'no' answers for PIP seen in Figure 1, it does not comprise the same respondents.Most who answered yes to PIP disagreed with the statement (87.5%).Of those who answered no to PIP, there was an even split between disagreement (50%) and agreement (50%) with the statement.
To further explore this relationship, responses were also analysed in their original form as ordinal variables (1 = strongly disagree, 5 = strongly agree).
Table 7 presents the results of a Mann-Whitney U test performed to assess differences in mean ranks of choice scores between those who answered yes and no to PIP.

Table 7
A Mann-Whitney U test to show difference in mean ranks of choice scores between answers to PIP Table 7 shows that the mean rank is lower for respondents that answered yes (9.50), compared to those who answered no (14.50).This indicates that respondents that answered yes were more likely to disagree with the statement.However, this difference was not statistically significant (U = 16.000,p = .148).
Choice was also an element of Question 7 (see Appendix A), which asked respondents to classify AN.However, the cross-tabulation of classification of choice and PIP showed a non-statistically significant association (p = .531).This high p value combined with the fact that choice was only selected by a minority of respondents (n = 3) meant that there was unlikely to be enough data to detect a meaningful relationship between variables (Martínez-Mesa et al., 2014).Therefore, further analysis was not conducted.
Overall, these results do not provide substantial evidence to support that belief that AN is a choice affects students' attitudes towards PIP for people with AN.Though many respondents who answered yes to PIP disagreed that AN is a choice, responses were too mixed to draw definitive conclusions and findings were not statistically significant.

Discussion
Though the results of this study did not show a statistically significant association between stigma and endorsement of PIP for people with AN, respondents who answered no to PIP were nonetheless found to generally have higher levels of stigmatising beliefs than those who answered yes.Many scholars (see e.g., LoBiondo-Wood, 2018;Mehler et al., 2019) claim that although they may not be statistically significant, any differences highlighted in data analysis have potential to be significant to the discipline.Though it is widely used, the 0.05 significance value is still argued to be an arbitrary boundary, and conclusions based solely on their adherence to this may overlook important findings (Di Leo & Sardanelli, 2020;Wasserstein & Lazar, 2016).This is particularly salient in social science, as effects labelled non-significant can still have notable impacts on society and real people's lives (Ziliak & McCloskey, 2008).Therefore, the trends observed in this study's results should be considered valuable contributions to the knowledge base and not dismissed purely because of the p value.

Attitudes to PIP
This study found considerable support for PIP for people with AN, with 80% of respondents agreeing that people with the condition should be eligible to apply for the benefit.This is a positive finding and suggests that most respondents realised the significant impact AN can have on a person's dayto-day life.
It is possible that the sociocultural context of the COVID-19 pandemic ongoing at the time of the research may have contributed to these largely favourable attitudes to PIP.The pandemic stimulated a wide-scale increase in the number of people reliant on state welfare, which was speculated to potentially lead to more accepting attitudes towards claimants (Clair et al., 2021;Curtice, 2020).Preliminary research into postpandemic public attitudes to benefits suggests that these may be ameliorating, with people showing increased leniency towards those who may previously have been regarded undeserving (Duffy et al., 2021;Patrick et al., 2021).
Another reason for this finding may be the theory that people with illnesses and disabilities are generally regarded as deserving and not subject to the same scrutiny as other welfare claimants (Böheim & Leoni, 2018;Jensen & Petersen, 2017).However, as comparison between people with AN and other benefits claimants was outside the scope of this study, this theory cannot be substantiated by the current research.
Data analysis revealed a significant association between the classification of AN as a physical illness and agreement for PIP.This supports findings of both McAllister (2020) and Geiger (2021) that physical illness is often viewed as highly deserving of sickness and disability benefits.However, this study was not able to draw comparisons with the classification of AN as a mental illness, as the association between this classification and agreement for PIP was not statistically significant and many respondents simultaneously viewed AN as both a physical and mental illness.
Though the majority of the sample agreed that individuals with AN should be eligible to apply for PIP, the fifth that did not is still concerning.Irrespective of changes induced by the pandemic, British sickness and disability benefits have become increasingly aligned with the worklessness discourse over recent years, with policies more focused on determining which conditions are deserving of support (Böheim and Leoni, 2018;Ciccia et al., 2020;Wiggan, 2012).This enhanced conditionality has been linked with a deterioration in public attitudes towards claimants and argued to have intensified the scrounger narrative that positions people on sickness and disability benefits as unnecessarily dependent on taxpayer money (Briant et al., 2013;Burch, 2018).
Previous research has shown that claimants are aware of this narrative, and that it often results in feelings of guilt and shame (Garthwaite, 2015;Patrick, 2016).Furthermore, such negative perceptions have been associated with reduced benefit take-up (Baumberg, 2016).Correspondingly, lack of access to sickness and disability benefits has been linked to deteriorations in both physical and mental health (Saffer et al., 2018;Shefer et al., 2016).Therefore, views that somebody with AN is undeserving of applying for PIP could have detrimental impacts on a person's self-esteem and finances, and compound existing health issues.

AN stigma
In his seminal work, Goffman (1963) described a stigma as a characteristic that differs from societal norms and is thus seen as undesirable.Someone with such a trait is 'reduced... from a whole and usual person to a tainted, discounted one' (Goffman, 1963, p. 3). Link andPhelan (2001) believe the formation of stigma to be a multi-faceted process involving 'labeling, stereotyping, separation, status loss, and discrimination' (p.367).
Similarly, Tyler and Slater (2018) propose that stigma is a form of power that operates beyond the individual level and incorporates social and political structures.These structures activate discourses of stigma to control and negate citizens with socially undesirable characteristics, such as having a mental illness.This has been referred to by others (e.g., Hatzenbuehler, 2018;Henderson et al., 2014) as structural stigma that informs public opinion and policies in a way that restricts opportunities for stigmatised groups and compromises their wellbeing.Structural stigma has been repeatedly related to illness, particularly mental health conditions (e.g., Corrigan et al., 2004;Sheehan et al., 2017).
It is well documented that stigma can be greatly detrimental to a person's quality of life (Gates, 2019), with effects including lowered self-esteem (Vass et al., 2017), reduced access to employment (Ong et al., 2020), and social exclusion (Krupchanka & Thornicroft, 2017).Additionally, stigma of EDs has been associated with low levels of help-seeking and increased symptom severity (Foran et al., 2020).
This study extended the work of Crisafulli et al. (2010) and Bannatyne and Abel (2015) in recognising the potential link between AN stigma and endorsement for structural support for sufferers.The findings illustrate another way in which stigma can impact upon the lives of affected individuals; discrediting people with AN and discounting their right to social security.This stigma should therefore be considered structural.
However, despite its relationship with lack of agreement for PIP, overall stigma was low across the sample (M = 1.41,SD = 0.60), with most scores (95%) falling below the scale midpoint.The mean was below that elicited by the first use of the EDSS by Crisafulli et al. (2010), which demonstrated a value of 2.13 (SD = 0.52).Additionally, this study reported perceptions of AN that were largely more positive than previous research, particularly in regard to vanity.Across the sample, no respondents agreed that someone with AN 'only cares about looking good', despite this being one of the most highly endorsed viewpoints of the original EDSS study (Crisafulli et al., 2010).Stereotypes of people with EDs as vain are a persistent finding across the literature (Geerling & Saunders, 2015;Katterman & Klump, 2010;Mond et al., 2006), so it is an unexpected, but welcome, result that they were not found in this study.

AN and blame
Analysing the EDSS at subscale level, some findings appear more consistent with those of previous research.The highest mean subscale value was Blame (M = 1.68 SD = 0.99), which is a recurrent finding in studies that have utilised the EDSS (Bannatyne & Abel, 2015;Bannatyne & Stapleton, 2017;Crisafulli et al., 2010).Though in the current study most respondents still disagreed with the Blame statements, the noticeably higher endorsement of these items compared with others indicates that blame is a pivotal aspect of AN stigma.This finding is also consistent with previous studies that did not use the EDSS, as Crisp (2005), Angermeyer et al. (2013), and Geerling and Saunders (2015) all found significant evidence of people with EDs being blamed for their condition.
Though choice as an independent variable was not shown to have a statistically significant association with PIP, the Blame subscale statements could be interpreted to reflect choice through their references to responsibility and causation.Therefore, findings may indicate volitional stigma (Easter, 2012).While the EDSS encapsulates the unique stigma of EDs, some items may overlap with general perceptions of welfare deservingness; statements from the Blame subscale are also relevant to the Control element of CARIN (van Oorschot, 2000).Therefore, findings are consistent with previous studies (Jensen & Petersen, 2017;Laenen et al., 2019;McAllister, 2020), as higher endorsement of control over AN was associated with disagreement with government support for the condition.

Classification of AN
Separately from agreement with PIP, results offered an insight into how respondents classified AN.The variance and overlap in responses exemplify the general ambivalence around AN's classification and give weight to the notion of AN as a contested illness (Giles, 2006).Contested illnesses have been defined as conditions with uncertain causes, unclear effective treatments, and disputed classifications among professionals and the public (Schone, 2019;Swoboda, 2006).Giles (2006) identifies AN as a contested illness due to its combination of physical and mental symptoms and the widespread uncertainty about the role that psychological, physiological and sociocultural factors play in its onset.
Despite AN being widely referred to as a mental illness (e.g., NHS, 2021;van den Berg et al., 2019), some specialists have argued that psychiatric symptoms may be induced by physical effects of starvation, rather than vice versa (e.g., Gutiérrez & Carrera, 2021;Södersten et al., 2019).Furthermore, diagnosis of AN is dependent on weight and has a vast number of physical complications (WHO, 2020).Therefore, it is understandable that many respondents (65%) viewed AN as both a physical and mental illness.
Importantly, people with AN often experience high levels of physical, social and occupational impairment, leading some to consider it a significantly disabling condition (Mond et al., 2004;Siegel & Sawyer, 2019;Tan et al., 2020).Regarding long-term illnesses more generally, there has been consistent hesitancy among sufferers, policymakers and the public to consider long-term illnesses as types of disability, despite acknowledging that they have significantly disabling symptoms (Hale, 2018;Price et al., 2020).The findings of this study indicate this hesitancy may apply to AN, as only 25% of the sample classified the condition as a disability, despite all respondents recognising it as some form of illness lasting for at least one year.

Conclusion
The main findings of this study were that most respondents agreed that individuals with AN should be eligible to apply for PIP, though stigma of AN was associated with lack of agreement with PIP.This research did not find substantive evidence that perceptions of AN being a choice were associated with attitudes towards PIP.Overall, stigma towards AN was not prevalent among respondents, which was a welcome result.However, views reflecting volitional stigma were still present, and some respondents blamed sufferers for having AN.

Study limitations
Though this study fulfilled its aim and thus offered a valuable starting point for investigating the impact of stigma on perceived deservingness of benefits, it did have several limitations.Firstly, the sample size was small (n = 20), which is likely to have contributed to the observed scarceness of statistical significance (Martínez-Mesa et al., 2014).The low response rate may be explained by students experiencing survey fatigue (Van Mol, 2017) and decreased levels of motivation and engagement amidst the COVID-19 pandemic (Daniels et al., 2021;Hill & Fitzgerald, 2020).Despite the limited data pool, small-scale studies are useful for initial investigation of phenomena (Denscombe, 2014), so this project is still regarded to have considerable merit in the field.
Secondly, findings were potentially influenced by the adaptation of the EDSS.Though included items were thought to satisfactorily reflect the four elements of AN stigma, respondents still may have responded more/less favourably to excluded items from the full scale, thus resulting in notably different overall stigma scores.
Another limitation of this research was the homogeneity of the sample.AN has historically been regarded a female problem (Bray, 1996;MacLean et al., 2015;Smith et al., 2021), which may have made females more inclined to respond (Saleh & Bista, 2017).However, attitudes of people who do not identify as female may differ from those reported by this research.Additionally, as Human and Health Sciences incorporates courses such as Psychology, Mental Health Nursing and Occupational Therapy, respondents may have had teaching on and exposure to AN that resulted in knowledge and understanding of the condition atypical of the general student population.This may have contributed to the largely non-stigmatising attitudes found.

Future research recommendations
It would be beneficial to repeat this research in a larger sample that is representative of the British population to allow results to be generalisable (Hartley et al., 2021), and to detect differences between responses from people with different characteristics (Hughes et al., 2016), for example those of different genders, ethnicities and educational backgrounds.Additionally, a larger sample may result in more cases of statistical significance seen in this study -the lack of which particularly impeded investigation of how perceptions of choice to agreement with PIP.
The largely positive views found by this study may indicate that attitudes towards AN have ameliorated since previous research, which is consistent with claims from charities and academics that mental illness stigma has reduced, possibly owing to anti-stigma campaigns (e.g., Henderson et al., 2020;TTC, 2021a).Further research is needed to investigate this, as one small-scale study is not sufficient to substantiate the theory.Moreover, it is worth noting that this study was unintentionally launched during ED Awareness Week 2021 (Beat, 2021a), which may have contributed to the largely favourable views.However, long-term efficacy of such interventions is unknown (Doley et al., 2017), so it would be worthwhile to repeat this research at a later date.
It may also be beneficial for future research to utilise the full EDSS scale, or different adaptations, to analyse the impact of including different statements to measure stigma.Furthermore, this study used the examples of AN and PIP, but future research could broaden the evidence base by investigating attitudes towards other EDs and benefits, which may be viewed differently.
Finally, this study demonstrated just one way that ED stigma can impact upon other attitudes towards sufferers.Future research should endeavour to understand more about potential impacts of stigma, analysing, for example, effects of ED stigma on respondents' attitudes towards healthcare or employment opportunities for sufferers.
Overall, this study has highlighted a crucial way in which the stigma of AN can impact sufferers' lives.This research made a novel contribution to the knowledge base on both EDs and benefits, and provided a starting point for other scholars to build upon in future.

Please read the following information carefully:
Anorexia nervosa is a condition where a sufferer has a significantly low body weight or rapid weight loss caused by behaviours intended to reduce overall calorie intake, such as restrictive eating, excessive exercise or self-induced vomiting (World Health Organization, 2020).Physical complications of anorexia nervosa can include tiredness, weakness, concentration and memory difficulties, low blood pressure, osteoporosis (weakened bones), fertility issues, and heart problems (National Health Service, 2021).
Question 5: How strongly do you agree that the following statements apply to a person with anorexia nervosa?(Please read each statement carefully and select an option for each statement.1 means strongly disagree and 5 means strongly agree.)5a: 'Their illness is not as serious as other mental illnesses.'5b: 'Their illness is not as serious as other physical illnesses.'5c: 'They are selfish.'5d: 'They only care about looking good.' 5e: 'They are weak.'5f: 'They are pathetic for not being able to control their anorexia.'5g: 'They caused their anorexia.'5h: 'They are responsible for their anorexia.'Less than 6 months Over 6 months but less than 1 year 1-2 years 3-5 years 6-10 years Over 10 years

Please read the following information carefully:
Personal Independence Payment (PIP) is a type of benefit available to help with additional costs of living for people with long-term health conditions or disabilities.PIP is available to both employed and unemployed UK citizens aged between 16 years and state pension age.People are eligible to apply for PIP if they have a health condition or disability that causes them to have difficulty with daily living and/or getting around.Applying for PIP does not mean that a person will automatically receive itthey will have to undergo an assessment to determine the effects of their condition on their daily life (HM Government, n.d.).
Question 9: Do you believe that people with anorexia nervosa should be eligible to apply for Personal Independence Payment (PIP)?

Yes No
Please click the blue arrow button to submit your responses and proceed to the end of the survey.
not to say Question 3: What year of undergraduate study are you in at the University of Huddersfield?

[
NB: Each statement had an interactive answer scale with the relevant options.]Question 6: How strongly do you agree with the following statement?: 'A person with anorexia nervosa can choose to stop their behaviour if they want to.' (Please read the statement carefully and select an option. 1 means strongly disagree and 5 means strongly agree.)[NB:The statement had an interactive answer scale with the relevant options.]Section Three: Classifying anorexia nervosa and providing support Question 7: Which of these labels do you think apply to anorexia nervosa?Please select all that apply On average, how long do you think somebody with anorexia nervosa will have the condition?

Table 1
Frequency of responses for each classification label

Table 4 A
Mann-Whitney U test to show difference in mean ranks of overall stigma scores between answers to PIP

Table 5
Levels of disagreement with EDSS items, split between yes and no responses to PIP