A Metascientific Review of the Evidential Value of Acceptance and Commitment Therapy for Depression.

In the past three-and-a-half decades, nearly 500 randomized controlled trials (RCTs) have examined Acceptance and Commitment Therapy (ACT) for a range of health problems, including depression. However, emerging concerns regarding the replicability of scientific findings across psychology and mental health treatment outcome research highlight a need to re-examine the strength of evidence for treatment efficacy. Therefore, we conducted a metascientific review of the evidential value of ACT in treating depression. Whereas reporting accuracy was generally high across all trials, we found important differences in evidential value metrics corresponding to the types of control conditions used. RCTs of ACT compared to weaker controls (e.g., no treatment, waitlist) were well-powered, with sample sizes appropriate for detecting plausible effect sizes. They typically yielded stronger Bayesian evidence for (and larger posterior estimates of) ACT efficacy, though there was some evidence of significance inflation among these effects. RCTs of ACT against stronger controls (e.g., other psychotherapies), meanwhile, were poorly powered, designed to detect implausibly large effect sizes, and yielded ambiguous-if not contradicting-Bayesian evidence and estimates of efficacy. Although our review supports a view of ACT as efficacious for treating depression compared to weaker controls, future RCTs must provide more transparent reporting with larger groups of participants to properly assess the difference between ACT and competitor treatments such as behavioral activation and other forms of cognitive behavioral therapy. Clinicians and health organizations should reassess the use of ACT for depression if costs and resources are higher than for other efficacious treatments. Clinical trials contributing effects to our synthesis can be found at https://osf.io/qky35.

The Building Healthy Eating and Self-Esteem Together for University Students Mobile App to Treat Eating Disorders: User-Centered Research Design and Feasibility Study.

BACKGROUND: University students are an at-risk group for the development of eating disorders (EDs); however, many college campuses lack sufficient resources to provide ED specialty care. Students report unique reasons for not seeking ED treatment, including the desire to solve the problem on their own (eg, seeking help from friends, self-medicating, or waiting to see if their problems improve), inability to afford treatment, lack of time to participate in the treatment, fear of seeing their primary care physician, and lack of recognition of their issues as an ED. Mobile health (mHealth) apps may be a cost-effective, helpful adjunctive tool to overcome personal and systemic barriers and encourage help seeking. OBJECTIVE: This paper describes the development, usability, and acceptability of the Building Healthy Eating and Self-Esteem Together for University Students (BEST-U) mHealth smartphone app, which is designed to fill critical gaps in access to ED treatment on college campuses. METHODS: We undertook a 4-phase iterative development process that focused on user-centered design. The 4 phases included needs assessment based on literature reviews, prototype development and initial evaluation in a pilot trial, redesign, and further pilot-testing to assess the usability and acceptability of the final version of the mHealth app. Acceptability and user satisfaction were assessed using an ad hoc survey that ranged from 1 (strongly disagree) to 7 (strongly agree). RESULTS: Our needs assessment identified a lack of accessible and affordable treatments for university students. To help meet this need, the BEST-U prototype was designed as an 11-week program that provided interactive, weekly modules that focused on second- and third-wave cognitive behavioral skills. The modules focused on topics such as psychoeducation, reducing thought distortions and body checking, improving body image, interpersonal effectiveness, and behavior chain analysis. The content included interactive quizzes, short answer questions, daily and weekly logs, and surveys completed in the app. BEST-U was paired with brief 25-30 minutes of weekly telehealth coaching sessions provided by a licensed provider or supervised trainee. Pilot-testing revealed minor issues with one module of the app content, which some participants viewed as having low relevance to their experience and therapist concerns about the organization of the app content. These issues were addressed through the removal, addition, and reorganization of BEST-U modules, with the help of therapists-in-training across 2 workshops. The revised version of the BEST-U app had a grand mean acceptability rating of 5.73 out of 7. The participants completed 90.1% (694/770) of the BEST-U modules, indicating high compliance. CONCLUSIONS: BEST-U is a new, acceptable, and user-friendly mHealth app to help therapists deliver brief, evidence-based cognitive behavioral interventions. Owing to its acceptability and user-friendly nature, BEST-U has high user compliance and holds promise for future implementation and dissemination in university mental health settings.

A pilot multiple-baseline study of a mobile cognitive behavioral therapy for the treatment of eating disorders in university students.

OBJECTIVE: Eating disorders (EDs) are serious psychiatric disorders associated with substantial morbidity and mortality that are prevalent among university students. Because many students do not receive treatment due to lack of access on university campuses, mobile-health (mHealth) adaptations of evidence-based treatments represent an opportunity to increase treatment accessibility and engagement. The purpose of this study was to test the initial efficacy of Building Healthy Eating and Self-Esteem Together for University Students (BEST-U), which is a 10-week mHealth self-guided cognitive-behavioral therapy (CBT-gsh) app that is paired with a brief 25-30-min weekly telehealth coaching, for reducing ED psychopathology in university students. METHOD: A non-concurrent multiple-baseline design (N = 8) was used to test the efficacy of BEST-U for reducing total ED psychopathology (primary outcome), ED-related behaviors and cognitions (secondary outcomes), and ED-related clinical impairment (secondary outcome). Data were examined using visual analysis and Tau-BC effect-size calculations. RESULTS: BEST-U significantly reduced total ED psychopathology and binge eating, excessive exercise, and restriction (effect sizes ranged from -0.39 to -0.92). Although body dissatisfaction decreased, it was not significant. There were insufficient numbers of participants engaging in purging to evaluate purging outcomes. Clinical impairment significantly reduced from pre-to-post-treatment. DISCUSSION: The current study provided initial evidence that BEST-U is a potentially efficacious treatment for reducing ED symptoms and ED-related clinical impairment. Although larger-scale randomized controlled trials are needed, BEST-U may represent an innovative, scalable tool that could reach greater numbers of underserved university students than traditional intervention-delivery models. PUBLIC SIGNIFICANCE: Using a single-case experimental design, we found evidence for the initial efficacy of a mobile guided-self-help cognitive-behavioral therapy program for university students with non-low weight binge-spectrum eating disorders. Participants reported significant reductions in ED symptoms and impairment after completion of the 10-week program. Guided self-help programs show promise for filling an important need for treatment among university students with an ED.

Eating-disorder psychopathology in female athletes and non-athletes: A meta-analysis.

OBJECTIVE: There is ongoing discussion about whether sports participation is a risk or protective factor for eating disorders (EDs). Research is mixed, with some studies suggesting that athletes have higher mean levels of ED psychopathology compared to nonathletes, while other studies suggest the opposite effect or no differences. The purpose of the current meta-analysis was to identify whether female athletes reported higher mean levels of ED psychopathology compared to nonathletes. METHOD: Following PRISMA guidelines, we identified 56 studies that reported ED psychopathology for female athletes and nonathletes. A three-level random-effects model of between- and within-study variance was completed for the following outcome variables: overall ED psychopathology, body dissatisfaction, drive for thinness, restricting, and loss-of-control eating. RESULTS: Athletes reported lower levels of body dissatisfaction compared to nonathletes (g = -.21, p < .0001). Athletes and nonathletes reported similar levels of overall ED psychopathology, drive for thinness, restricting, and loss-of-control eating on average. Sport type significantly moderated standardized mean difference effect sizes of ED psychopathology in athletes versus nonathletes. Effect sizes comparing levels of drive for thinness, restricting, and loss-of-control eating in athletes versus nonathletes were larger for studies with athletes participating in aesthetic/lean sports compared to nonaesthetic/nonlean sports. DISCUSSION: Findings from this meta-analysis could inform future ED prevention and treatment in female athletes by providing further evidence that athletes in aesthetic/lean sports may report higher levels of ED psychopathology. Participating in nonaesthetic/nonlean sports may be a protective factor for experiencing less body dissatisfaction. PUBLIC SIGNIFICANCE STATEMENT: The current meta-analysis summarized findings from 56 studies that assessed levels of disordered eating, body dissatisfaction, dietary restricting, and loss-of-control eating in female athletes and nonathletes. Athletes reported lower levels of body dissatisfaction compared to nonathletes, highlighting that participation in sport could have some protective factors. Athletes participating in sports that require weight categories (e.g., judo) and sports that emphasize thinness/leanness (e.g., gymnastics and distance running) had higher levels of disordered eating relative to athletes participating in other types of sports that do not emphasize thinness/leanness (e.g., volleyball and basketball).

OBJETIVO: Existe un debate abierto sobre si la participación en los deportes es un factor de riesgo o protector para los trastornos de la conducta alimentaria (TCA). La investigación es mixta, con algunos estudios que sugieren que los atletas tienen niveles medios más altos de psicopatología de TCA en comparación con los no atletas, mientras que otros estudios sugieren el efecto opuesto o ninguna diferencia. El propósito del presente metanálisis fue identificar si las atletas femeninas reportaron niveles medios más altos de psicopatología de TCA en comparación con las no atletas. MÉTODO: Siguiendo las guías PRISMA, se identificaron 56 estudios que informaron psicopatología de TCA para atletas femeninas y no atletas. Se completó un modelo de efectos aleatorios de tres niveles de varianza entre y dentro del estudio para las siguientes variables de resultado: psicopatología general de TCA, insatisfacción corporal, impulso por la delgadez, restricción y pérdida de control de la alimentación. RESULTADOS: Las atletas reportaron niveles más bajos de insatisfacción corporal en comparación con las no atletas (g = -.21, p <.0001). Las atletas y las no atletas reportaron niveles similares de psicopatología general de TCA, impulso por la delgadez, restricción y pérdida de control de la alimentación en promedio. El tipo de deporte moderó significativamente los tamaños del efecto de la diferencia de medias estandarizada de la psicopatología de TCA en atletas versus no atletas. Los tamaños del efecto que compararon los niveles de impulso por la delgadez, la restricción y la pérdida de control de la alimentación en atletas versus no atletas fueron mayores para los estudios con atletas que participaron en deportes que valoran lo estético/cuerpo magro, esbelto, en comparación con deportes que no valoran lo estético/cuerpo magro, esbelto. DISCUSIÓN: Los hallazgos de este metanálisis podrían informar la prevención y el tratamiento futuros de los TCA en atletas femeninas al proporcionar más evidencia de que las atletas en deportes que dan un gran valor a lo estético o al cuerpo magro, esbelto, pueden reportar niveles más altos de psicopatología de TCA. Participar en deportes que no dan valor a lo estético o al cuerpo magro, puede ser un factor protector para experimentar menos insatisfacción corporal.

Identifying central symptoms of eating disorders among ethnic and racial minority women.

Experiencing eating disorder symptoms is associated with maladaptive outcomes and impairment in functioning. A paucity of research exists examining eating disorder symptoms among ethnic/racial minority women. Using a network analysis, we evaluated core symptoms of eating disorder psychopathology and the degree of association between eating disorder symptoms in a sample of ethnic/racial minority women. Participants were 296 Black, 261 Hispanic, and 261 Asian American women recruited across the United States to complete an online survey. Inclusionary criteria yielded a sample with high eating disorder psychopathology. The Network Comparison Test was used to identify differences in networks between groups and yielded no significant differences between the three ethnic/racial groups. Thus, one network analysis on the entire sample was conducted in the main analyses. However, separate group analyses are presented in the online supplemental materials. Consistent with the transdiagnostic theory of eating disorders, weight concerns (i.e., strong desire to lose weight and fear of weight gain) emerged as central symptoms. Discrepant from findings with predominantly White samples, purging emerged as a central symptom as well, while shape concerns did not. Interestingly, having to weigh oneself weekly, having a flat stomach, fasting, and compulsive exercising were on the periphery of the network. Findings are discussed in terms of clinical implications and comparative similarities and differences when addressing the existing literature. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Measurement invariance of the Eating Pathology Symptoms Inventory (EPSI) in adolescents and adults.

Adolescence is a common period for eating disorder (ED) onset. The availability of psychometrically sound measures of ED psychopathology enables clinicians to accurately assess symptoms and monitor treatment outcomes continuously from adolescence and adulthood. The purpose of this study was to assess if the Eating Pathology Symptoms Inventory (EPSI) is invariant across adolescents and adults. Participants (N = 29,821) were adolescent (n = 5250) and adult (n = 24,571) users of the Recovery Record (RR) mobile phone application who provided EPSI responses through the application. Measurement invariance testing was conducted to assess invariance of the EPSI Body Dissatisfaction, Restricting, Excessive Exercise, Purging, Cognitive Restraint, and Binge Eating scales across adolescents (age 13 through 17) and adults (age 18 and older). Findings indicated that all EPSI factors administered in the RR app replicated in both adolescent and adult users. The EPSI factor structure was largely equivalent in adolescents and adults, demonstrating evidence for configural and metric invariance, as well as some evidence for scalar invariance. Our results indicated that EPSI scales measured the same constructs across development. Clinicians and researchers may benefit from utilizing the EPSI to measure ED psychopathology in adolescents and for continued progress monitoring into adulthood.

Validation of the factor structure of the Eating Pathology Symptoms Inventory in an international sample of sexual minority men.

Sexual minority individuals are at greater risk for the development of eating-disorder (ED) psychopathology. Despite the importance of understanding ED symptoms in sexual minority men, most ED measures were developed and validated in heterosexual, young adult, white women. The psychometric properties of ED measures in diverse populations remain largely unknown. The purpose of this study was to test: 1) whether the eight-factor structure of the Eating Pathology Symptoms Inventory (EPSI) replicated in sexual minority men and 2) group-level mean differences between gay and bisexual men on the eight EPSI scales. International participants (N = 722 sexual minority men from 20 countries) were recruited via the Grindr smartphone application. Confirmatory factor analysis (CFA) was completed using a weighted least square mean and variance adjusted estimator. Group differences in eating pathology between gay and bisexual men were tested using independent samples t-tests. The CFA model fit was good on all fit indices (CFI/TLI > 0.90, RMSEA < 0.06). Gay and bisexual men only differed on the EPSI Binge Eating scale. The results of this investigation suggest that the EPSI may be a useful tool for understanding eating pathology in this population. Using psychometrically sound assessment tools for sexual minority men is a vital piece of treatment planning and clinical decision making. The current study fills an important gap in the clinical and research literature by testing the validity and psychometric properties of a commonly used ED measure in sexual minority men.

Food insecurity associated with elevated eating disorder symptoms, impairment, and eating disorder diagnoses in an American University student sample before and during the beginning of the COVID-19 pandemic.

OBJECTIVE: This study tested the association between food insecurity and eating disorder (ED) pathology, including probable ED diagnosis, among two cohorts of university students before and during the beginning of the COVID-19 pandemic. METHOD: Students (n = 579) from a large Midwestern American university completed self-report questionnaires assessing frequency of ED behaviors, ED-related impairment, and individual food insecurity as measured by the Eating Disorder Diagnostic Scale 5, Clinical Impairment Assessment, and Radimer/Cornell, respectively. Chi-square tests and MANOVA with post-hoc corrections were conducted to compare demographic characteristics, ED pathology, and probable ED diagnosis prevalence between students with and without individual food insecurity. RESULTS: Partially supporting hypotheses, MANOVA indicated significantly greater frequency of objective binge eating, compensatory fasting, and ED-related impairment for students with food insecurity compared with individuals without food insecurity. Chi-squared tests showed higher prevalence of ED diagnoses among individuals with food insecurity compared with those without food security (47.6 vs. 31.1%, respectively, p < .01, NNT = 6.06), specifically bulimia nervosa and other specified feeding and eating disorder. There were no differences in food insecurity before or during the beginning of the COVID-19 pandemic. DISCUSSION: Consistent with prior literature, food insecurity was associated with elevated ED psychopathology in this sample. Findings emphasize the importance of proper ED screening for college students vulnerable to food insecurity and EDs.

Development and initial validation of the Eating Pathology Symptoms Inventory-Clinician-Rated Version (EPSI-CRV).

Proper assessment and diagnosis of eating disorders (EDs) are critical to determine to whom prevention and treatment efforts should be targeted, the extent to which treatment is working, and when an individual has recovered. Although existing ED diagnostic interviews have numerous strengths, they also have certain limitations, including poor internal consistency, low discriminant validity, and poor factor-structure replicability. The purpose of the current study was to address problems of past ED diagnostic interviews through the creation of a new clinician-rated interview-the Eating Pathology Symptoms Inventory-Clinician-Rated Version (EPSI-CRV). The EPSI-CRV was designed to measure dimensional constructs assessed in the self-report version of the EPSI and generate current Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) diagnoses. Participants were community-recruited adults with a DSM-5 ED (N = 257). Participants completed self-report and interview-based measures of eating, mood, and anxiety disorders and self-report measures of psychiatric impairment. The EPSI-CRV demonstrated evidence for interrater reliability, convergent and discriminant validity, and a good-fitting factor structure. EPSI-CRV dimensions showed concurrent validity for distinguishing among ED diagnoses. Baseline EPSI-CRV dimensions significantly predicted psychiatric impairment at baseline but not at 1-year follow-up. Although some scales had lower internal consistency than ideal, internal consistency values were similar to those of other established diagnostic measures. The EPSI-CRV appears to represent a promising new interview that can be used across a variety of clinical and research settings. Interested readers can access the EPSI-CRV and relevant training materials here: https://kuscholarworks.ku.edu/handle/1808/29616. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Eating disorder core symptoms and symptom pathways across developmental stages: A network analysis.

Eating disorders (EDs) often develop during adolescence and early adulthood but may persist, arise, or reemerge across the life span. Research and treatment efforts primarily focus on adolescent and young adult populations, leaving large knowledge gaps regarding ED symptoms across the entire developmental spectrum. The current study uses network analysis to compare central symptoms (i.e., symptoms that are highly connected to other symptoms) and symptom pathways (i.e., relations among symptoms) across five developmental stages (early adolescence, late adolescence, young adulthood, early-middle adulthood, middle-late adulthood) in a large sample of individuals with EDs (N = 29,902; N = 32,219) in two network models. Several symptoms related to overeating, food avoidance, feeling full, and overvaluation of weight and shape emerged as central in most or all developmental stages, suggesting that some core symptoms remain central across development. Despite similarities in central symptoms, significant differences in network structure (i.e., how symptom pathways are connected) emerged across age groups. These differences suggest that symptom interconnectivity (but not symptom severity) might increase across development. Future research should continue to investigate developmental symptom differences in order to inform treatment for individuals with EDs of all ages. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Application of network analysis to investigate sex differences in interactive systems of eating-disorder psychopathology.

OBJECTIVE: Although men comprise 25% of persons with eating disorders (EDs), most research has focused on understanding EDs in women. The theoretical framework underlying common ED treatment has not been rigorously tested in men. The purpose of this study was to compare the interconnectivity among ED symptoms in men versus women. METHOD: Participants (N = 1,348; 50% men) were individuals with anorexia nervosa, bulimia nervosa, binge-eating disorder, or other specified feeding or eating disorder who were users of Recovery Record, a smartphone app for monitoring ED symptoms. Participants were matched on age and duration of illness. Network analysis was used to create networks of symptoms for both sexes. Strength centrality, network stability, and bootstrapped centrality differences were tested. The network comparison test (NCT) was used to identify sex differences between networks. Key players analysis was used to compare fragmentation of each network. RESULTS: For both sexes, items related to binge eating and restricting emerged as highest in strength centrality. The NCT identified significant differences global strength (p = .03) but not network invariance (p = .06) suggesting that although the structure of the networks was not statistically different, the strength of the connections within the network was greater for women. Key players analysis indicated that both networks were similarly disrupted when important nodes within the network were removed. DISCUSSION: Findings suggested that there are more similarities than differences in networks of EDs in men and women. Results have important clinical implications by supporting theoretical underpinnings of cognitive-behavioral models of EDs in both men and women.

Ethnic differences in eating disorder prevalence, risk factors, and predictive effects of risk factors among young women.

Findings regarding ethnic differences in eating disorder diagnoses and risk factors have been mixed. This study evaluated whether there are ethnic differences in eating disorder prevalence, risk factors, and the predictive relations of the risk factors to future eating disorder onset. We used a large sample of young women followed longitudinally over three years to increase sensitivity to detect differences and to provide the first test of ethnic differences in the relation of risk factors to future onset of eating disorders. Females with body image concerns (N = 1177) were recruited from high schools and colleges for trials of a body acceptance eating disorder prevention program. They completed surveys and interviews at baseline and at 1-, 6-, 12-, 24-, and 36-month follow-up. Significant differences between ethnic groups were found for two of the 13 baseline risk factors: thin-ideal internalization and body mass index. No significant differences in later onset rates among ethnic groups were found. There were also no reliable ethnic differences in the relation of risk factors for future eating disorder onset. These findings suggest that eating disorders affect ethnic minorities as much as Whites and that there are more overlapping risk factors shared among various ethnic groups than differences.

The Athletes' Relationships with Training scale (ART): A self-report measure of unhealthy training behaviors associated with eating disorders.

OBJECTIVE: Several studies indicate that eating-disorder (ED) psychopathology is elevated in athletes compared to non-athletes. The assessment of excessive exercise among athletes is a challenge because, compared to non-athletes, athletes are required to train at higher intensities and for longer periods of time. However, individuals participating in competitive sports are still susceptible to unhealthy physical-activity patterns. Most ED assessments were developed and normed in non-athlete samples and, therefore, do not capture the nuances of athletes' training experiences. The purpose of the current study was to develop and validate a clinically useful, self-report measure of unhealthy training behaviors and beliefs in athletes, the Athletes' Relationships with Training Scale (ART). METHOD: The initial item pool was administered to N = 267 women collegiate athletes who were participating in an ED prevention program study and N = 65 women athletes who were in ED treatment. RESULTS: Factor analyses indicated the ART had a four-factor structure. Factorial and construct validity of the ART were demonstrated. ART scores significantly predicted health care utilization and differed between athletes with an ED versus athletes without an ED. For athletes in ED treatment, ART scores significantly decreased from treatment admission to discharge. DISCUSSION: The ART showed evidence of strong psychometric properties and clinical utility. The ART could be helpful for clinicians and athletic trainers to help gauge whether athletes are engaging in unhealthy training practices that may warrant clinical attention and for tracking clinical outcomes in athletes with EDs who are receiving treatment.

New Horizons in Measurement: a Review of Novel and Innovative Approaches to Eating-Disorder Assessment.

PURPOSE OF REVIEW: Eating disorders are serious mental-health concerns that will affect over 30 million individuals in the USA at some point in their lives. Eating disorders occur across the lifespan, in a variety of ethnicities and races, in both men and women, and across the socioeconomic spectrum. Given the prevalence and severity of eating disorders, it is important that clinicians and researchers have access to appropriate assessment tools to aid in the early identification and treatment referral, differential diagnosis, treatment planning, and progress monitoring, and to ensure valid research findings. In this review, we describe novel and innovative assessment tools that were developed within the past 5 years for utilization in research and/or clinical practice with individuals with eating disorders. RECENT FINDINGS: We identified six multidimensional assessments for eating disorders, all of which can be administered online (with some also offering paper-and-pencil versions). Strengths of the measures included good internal consistency, test-retest reliability, and convergent validity. However, in part, due to problematic scale construction methods, certain scales had poor discriminant validity and most were developed and validated in mostly female samples. There are promising new eating disorder measures from which to choose; however, many measures continue to be limited by poor discriminant validity and need additional validation prior to incorporation into routine research and clinical practice.

The relationship between narrative classification of obesity and support for public policy interventions.

In 2013, the American Medical Association made the controversial decision to classify obesity as a "disease" in the hopes of encouraging research, reducing stigma, and ultimately lowering the prevalence of the condition. Critics argued that the disease label would reduce feelings of personal responsibility among the obese and therefore discourage healthy self-regulation, a possibility that has received some recent support in the psychological literature. However, public health issues such as obesity are complex and depend not only on personal action, but also on wider societal trends such as social policy interventions. In the present study, we systematically investigated the relationship between four narrative classifications of obesity ("sin", "addiction", "disorder" and "environment") and support for a variety of policy interventions designed to address the issue. An initial norming study revealed that the obesity narratives differed reliably in how much they attributed blame for the condition to the individual versus the environment. A correlational study showed that participants who agreed with narratives that blamed the individual were more likely to support policy interventions that penalized people for being overweight while participants who agreed with narratives that blamed the environment were more likely to support policy interventions designed to protect people suffering from obesity. A follow-up experiment revealed that these narratives had causal power as well: participants exposed to just one of the narratives were more likely to support policy interventions consistent with the blame attribution of the narrative for both obesity as well as anorexia. Individual differences in political ideology and personal experience with weight issues also influenced agreement with the narratives and support for particular policy interventions across these studies. These findings suggest that public messaging campaigns that utilize extended narratives may be a useful tool for increasing support for effective policy interventions.