Development of fotonovelas to raise awareness of eating disorders in Latinos in the United States / Desarrollo de fotonovelas para concienciar sobre trastornos de la conducta alimentaria en latinos en los Estados Unidos

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http://journals.iztacala.unam.mx/index.php/amta/

ARTICLE

Development

of

fotonovelas

to

raise

awareness

of

eating

disorders

in

Latinos

in

the

United

States

Mae

Lynn

Reyes-Rodríguez

a_,_∗

_,

_Marissa

_García

b

_,

_Yormeri

_Silva

d

_,

_Margarita

_Sala

c

_,

Michela

Quaranta

e

_,

_Cynthia

_Marie

_Bulik

a_,f_,g

a_Department_of_Psychiatry,_University_of_North_Carolina,_Chapel_Hill,_NC,_United_States

b_Department_of_Health_Policy_and_Management,_University_of_North_Carolina,_Chapel_Hill,_NC,_United_States

c_Department_of_Psychology,_Southern_Methodist_University,_Dallas,_TX,_United_States

d_Department_of_Psychology,_North_Carolina_State_University,_Raleigh,_NC,_United_States

e_Department_of_{Neuroscience,}_AOU_San_Giovanni_Battista,_Turin,_Italy

f_Department_of_Nutrition,_University_of_North_Carolina,_Chapel_Hill,_NC,_United_States

g_Department_of_Medical_Epidemiology_and_{Biostatistics,}_Karolinska_Institutet,_Stockholm,_Sweden

Received16November2015;accepted8March2016 Availableonline18May2016

KEYWORDS

Fotonovela; Eatingdisorders; Prevention; Latinos; Awareness

Abstract Theaimofthisstudywastodevelopfotonovelas,apopulartypeofgraphicnovel intheLatinopopulation,toraise awarenessandeducateabouteatingdisorders(EDs).Four illustratedcartoonsandscriptstailoredforadultsandadolescentsofbothsexeswerepresented infocusgroupsandanin-depthinterview.SeventeenLatinoadults(14females;3males)and 10adolescents(9females;1male)participatedinthestudy.Participantsfoundthefotonovelas interesting,andeye-catchingthantraditionalbrochures.TheuseofSpanglishandclariﬁcation ofdifferencesacrossEDsweresuggestedbyadolescentfemales.Maleadultssuggestedchanging the title tofocus onthe health consequences ofEDsin ordertocatch the maleattention inreadingthestory. Basedonthereceptivitywe foundinthisstudy,fotonovelacouldbea promisingavenuetoraiseawarenessandtoeducatetheLatinocommunityintheUnitedStates aboutEDs.

∗_{Corresponding}_author.

E-mailaddress:maelynnreyes@med.unc.edu(M.L.Reyes-Rodríguez).

PeerReviewundertheresponsibilityofUniversidadNacionalAutónomadeMéxico.

http://dx.doi.org/10.1016/j.rmta.2016.03.002

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PALABRASCLAVE

Fotonovelas; Trastornosdela conducta alimentaria; Prevención; Latinos; Concienciación

Desarrollodefotonovelasparaconcienciarsobretrastornosdelaconducta alimentariaenlatinosenlosEstadosUnidos

Resumen El objetivo de este estudio fuedesarrollar fotonovelas, un tipo de novela grá-ﬁca popular enla población latina, para crear conciencia yeducar sobre lostrastornos de laconductaalimentaria(TCA).Cuatrocaricaturasilustradasyguionesadaptadosparaadultos yadolescentesdeambossexosfueronpresentadosendiscusionesfocalesyenunaentrevistade profundidad.Diecisietelatinosadultos(14mujeres;3hombres)y10adolescentes(9féminas; 1varón)participaronenelestudio.Losparticipantesencontraronlasfotonovelasinteresantes yquecaptabanmáslaatenciónquelosfolletostradicionales.Elusodelespanglishyla clari-ﬁcacióndelasdiferenciasentrelosTCAfueronsugeridosporlasadolescentesfemeninas.Los adultosvaronessugirieroncambiareltítulo,queseenfocaraenlasconsecuenciasenlasalud delosTCAparaquellamelaatenciónenloshombresaleerlahistoria.Basadoenlaaceptación encontrada enesteestudio, la fotonovelapudieraser unaavenidaprometedorapara crear concienciayeducaralacomunidadlatinasobrelosTCAenlosEstadosUnidos.

Introduction

Creativeapproachesarerequired toenhance early recog-nitionof eatingdisorders(EDs) andreduce mental health care disparities in the Latino population. Latinos/as with a history of EDs are less likely touse mental health ser-vices(Marquesetal.,2011)andtobereferredforfurther evaluationbyphysicians(Becker,Franko,Speck,&Herzog, 2003;Franko,Becker,Thomas,& Herzog,2007)than non-Latino whites. Several barriers to seeking treatment for mentalhealthproblemsgenerallyandEDsspecificallyhave beenidentifiedin theLatinopopulation,includinglack of knowledge(Britigan,Murnan,&Rojas-Guyler,2009), finan-cialand languagebarriers, lackof informationaboutEDs, shame,not knowing wheretogo for treatment, believing thatonecangetbetterontheirown,believingthateating problems are not serious enough to seek help (Cachelin & Striegel-Moore, 2006; Reyes-Rodríguez, Ramírez, Davis, Patrice, & Bulik, 2013), family privacy, and not being readytochange (Cachelin& Striegel-Moore, 2006; Reyes-Rodríguezetal., 2013).Barriers totreatment arefurther exacerbatedbythestigmaassociatedwithseekingcarefor EDs(Becker,HadleyArrindell,Perloe,Fay,&Striegel-Moore, 2010).

TheestimatedlifetimeprevalenceintheUnitedStatesof anorexianervosaamongLatinosis.08%inwomenand.03% inmen,ofbulimianervosa1.9%inwomenand1.3%inmen, andofbingeeatingdisorder2.3%inwomenand1.6%inmen (Alegriaetal.,2007).Itisconcerningthat,despitesimilar prevalenceestimateswithwhites,Latino/asarelesslikely tousemental health services andbe referredfor further evaluationbecauseEDsareseriousmedicalconditionsand amajorcauseofpsychiatricandmedicalmorbidity,often impairing several areas of functioning (Kessler, Berglund, etal.,2013;Kessler,Shahly,etal.,2013).

Critical questions remain regarding how we can best raiseawareness,engage,andretainLatinosin treatment. Psychoeducation about EDs was identiﬁed as one of the areas that should be addressed in Latinas living in the

United Statesaspart of a multilevelandculturally sensi-tiveinterventionmodel(Reyes-Rodríguezetal.,2013).The integrationofcultureandcontexthasbeenrecommended as a standard practice in clinical intervention, research, andeducation(seetheAmericanPsychologicalAssociation guidelines)toinformpsychologistsaboutissuesofdiversity (APA,2003).Culturallysensitivepsychoeducational materi-als focusing ontopicssuch asidentiﬁcation of symptoms, destigmatization,theimportanceofseekinghelpand avail-able resources for treatment would help educate Latinos aboutEDs.Therefore,theuseoffotonovelas,apopulartype ofgraphicnovelintheLatinopopulation,couldbea promis-ingavenuetoraiseawarenessandtoeducatethecommunity aboutEDs.

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DuetothelackofeducativematerialsaboutEDsfor Lati-nosintheUnitedStates,themainpurposeofthisresearch studywastodevelopculturallysensitivepsychoeducational materialsthatraiseawarenessandeducatetheLatino popu-lationaboutEDs.Thiswasachievedthrough:(a)developing fotonovelascriptsaboutEDsandartgraphicsforadolescent andadult Latinopopulations, (b)conducting focusgroups with adolescent and adult Latinos to gather feedback about theartandscriptsof fotonovelasand,(c)adapting and reﬁning the fotonovelas based on the focus groups’ feedback.

Methods

Participants

Participants were recruited through advertisements and outreach to diverse Latino community mental health clinicsandchurches. Themaininclusioncriterionforboth adolescents and adults was to be Latino or Latina. Par-ticipants who were at least 18 years old were invited tothe adult focusgroup, whereas participants who were between13and17yearsoldwereinvitedtotheadolescent focus group. The study was approved by the local Insti-tutionalReviewBoardandinformedconsentwascompleted for all adult participants. For adolescents, authorization from parents and assent forms from adolescents were collected.

Materials

Fotonoveladevelopment

Scripts’objectives

The topicsincludedin fotonovelascripts werebasedona previousformativestudyconductedwithLatinaswitha his-toryofEDs(Reyes-Rodríguezetal.,2013).The purposeof thescriptswastoenhanceliteracyaboutEDsbyproviding basicknowledge aboutEDs,reducestigmabyemphasizing thatEDsoccurinallracesandethnicgroupsincluding Lati-nos, and highlight the importanceof seeking professional help.

Scripts

Separatescriptstailoredforadultsandadolescentsofboth gendersweredeveloped by theresearchteam.Allscripts were written at a 4th grade reading level and with the useof aneutralSpanishinordertobeunderstandableby most Latinos regardless of the regional or national Span-ishdialect.Duringthescriptspreparation,issuesrelatedto language,age,sex,andrealisticsituationswereconsidered. Forexample,foradults,wedevelopedthescripts entirely in Spanishbecause mostadults areﬁrstgeneration immi-grantswhohavelessproﬁciencyoftheEnglishlanguagethan oftheSpanishlanguage.Incontrast,theadolescentscripts weremostlyinEnglishorSpanglish,asmostLatino/a ado-lescents aresecond generationimmigrants whoare more comfortablespeakingEnglishthanSpanish.Thecontentof fotonovelaswascreatedbasedonthedevelopmentprocess ofthetargetpopulationandtheclinicalexperienceofthe

ﬁrstauthortreatingandeducatingLatinoswithEDsforabout 20years.All scripts wererevised by threebilingualteam members.

Artdesignandprinting

Illustratedcartoonswereusedforallfotonovelas.Theuse ofphotographic design wasconsidered, especiallyfor the adult versions; however, factors such asbudget and time limitationsandthefinalintentiontoconveyacasualtone overaverysensitivetopicfor Latinos,wereconsideredin thefinaldecisiontousecartoons.ThestigmaofhavinganED intheLatinopopulationisgreaterthanthestigmaof hav-ingdepression orother mental health condition (Cachelin &Striegel-Moore,2006;Reyes-Rodríguezetal.,2013),and cartoonshavetheabilitytoassuageanxietyaboutsensitive topicswhile disclosingvaluablemedicalinformation(Moll, 1986).Aroughdraftofthegraphicdesignforeach fotonov-ela version was revised by the research team to ensure thateachcharacterwasproperlyrepresented.After reach-ingconsensus, the fotonovelas were printed in colour on glossy paper. Revised fotonovela versions were presented inseparatefocusgroups andin-depthinterviewaccording toparticipants’age (adultoradolescent) andsex(female ormale).Theinputfromthefocusgroupdiscussionswere integratedinthefinalversionsofthefotonovelas.

Procedure

Datacollection

Three separate focus groups and one in-depth interview were conducted with adults and adolescents to gather feedbackaboutthefotonovelas.Consentformsand demo-graphicinformationwerecollectedbeforethefocusgroup orin-depthinterviewdiscussion.Twofacilitatorsledthe dis-cussion usingpre-established guidelines(see Table 1)and one observer took notes. Focus groups and the in-depth interview were conducted in Spanish with adults and in EnglishorSpanglishwithadolescents.The discussionstook place either in a community based mental health clinic or church facilities. The familiarity and comfort of those settingsprovideda safeenvironmentfor theLatino popu-lationlivingaround thearea.Agroup discussion/in-depth interviewofapproximately1-hdurationwasconductedfor eachgroup.Allparticipants wereprovidedwitha copyof thefotonovela andwere read it by the facilitator at the beginningofeachgroupdiscussionandin-depthinterview. Alldiscussionswereaudiotapedandparticipantsreceiveda smallincentiveof$10ingratitudefortheirtime.Snacksand childcarewereprovided.

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Table1 Focusgroupguideline.

Domain Question

Artgraphic

1.Ingeneral,whatdoyouthinkaboutthematerialinthefotonovela? 2.Howattractiveorfamiliaristhegraphicart?

3.Howappropriatedoyouthinktheversionsareforyourgender? 4.Howappropriatedoyouthinktheartisforyourage?

5.Doyouthinkthereisachangethatcouldimprovethegraphicart? 6.Doyouthinkthelengthofthedialogueisadequate?

7.Istheformatofthefotonovelaadequateordoesitneedsomechange?

Content

1.Howclearandsimpledidyouﬁndthedialogueinthefotonovela?

2.Didyouhaveaproblemunderstandingoneofthedialoguesordidyoufindaworddifficulttounderstand? 3.Wouldthismaterialhavehelpedyoufindhelpforeatingdisorders?

4.Istheresomeinformationthatisnotincludedthatwouldbegoodtoinclude?

5.WhatdoyouthinkabouttheuseoffotonovelatoeducateLatinosabouteatingdisorders? 6.Didtheformatanddialoguehelpyouunderstandmoreabouteatingdisorders?

7.Anyothercommentyouwouldliketomake?

Results

Sample

Atotalof 17Latino/Latina heritageadults(14 females;3 males)and10adolescents(9females;1male)participated inthestudy.Eighty-eightpercent(88.2%;n=15)of adults self-identified asMexican and11.8% (n=2) didnotreport theirnationality. Sixty percent(60%; n=6) of adolescents self-identifiedasMexican,20percent(n=2)self-identified as Dominican, and 20 percent (20%; n=2) self-identified asAmerican. Adult agesranged between 20and 47 years (M=37;SD=7.72).Foradolescentstheagerangedbetween 13and17years(M=14.5,SD=1.34).Intermsofeducation, most of the adultsreported elementary school education level(35.3%;n=6)followedbyhighschoolorcollege edu-cationlevel(29.4%;n=5)andmiddleschooleducationlevel (17.6%;n=3).Threeadultsdidnotreporttheir education level(17.6%).Foradolescents,50%(n=5)reportedmiddle schooleducationleveland50%(n=5)ahighschool educa-tionlevel.

Adolescentfocusgroups

Twomaintopicsguidedthefocus-groupdiscussion:graphic art(i.e.,appealing, characters)andcontent(i.e.,length, story,title).Additionalcommentswereencouragedatthe endof the discussion. Adetailed description of discussed themes across groups is included in Table 2. In the ado-lescentfemalegroup thegraphic artandcharacterswere well accepted. They found the fotonovela interesting, moreappealing, andmore andeye-catching than a tradi-tionalbrochure. When asked about their thoughts onthe fotonovela,oneparticipantsaidthattheythoughtthatthe fotonovelawas‘‘interesante’’[interesting].

Nochangesweresuggestedforthegraphicartor charac-ters.Intermsofthecontent, participantsmentionedthat thestory waswell developed andrealistic.The length of

thestorywasfoundtobeadequate. Twomain suggestions byadolescentfemalesweretoaddmoreEnglishorSpanglish withinthepeerdialoguesandtoclarifydifferencesbetween EDs.Forexampleoneparticipantsaid‘‘másdiferenciaentre bulimiayanorexia’’[moredifferencebetweenbulimiaand anorexia].

Onlyoneparticipantshoweduptotheadolescentmale focus group. Therefore, we conducted an in-depth inter-viewinEnglishwithhim.Theparticipantfoundthegraphic appropriateandvisuallypleasing.Hesaid,‘‘It’srealistic’’ and ‘‘cartoons want you to keep reading. If it is very boringyoudon’twanttoreadit.’’Theparticipantsuggested thattheuseofcartoonswasbetterthanphotos, mention-ingthat‘‘actualpicturesaretooboring...toorealistic.’’He foundthelengthofthefotonovelasuitableandtheformat interestingandrelatableforadolescents.Ontheotherhand, theparticipantfoundsomewordsthatcouldbedifﬁcultto understand for non-Spanishspeakers.He alsowasunclear aboutwherehewouldgoforhelpifheweretohaveanED. Healsomentionedthatinreallifetheteacher/adultwould bemorelikelytoapproachthestudentwiththeED,instead ofthestudentseekinghelpbyhimself,andwemodiﬁedthe fotonovelastoryaccordingly.

Adultfocusgroups

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Table2 Feedbackfromfocusgroupdiscussions.

Focusgroup Graphics Content Changesmade

Adults

Females •Attractiveandvisually pleasing

•Attention-grabbing

•Self-identiﬁedwiththe characters

•Protagonistlooks overweight,whichcould causemisconceptionsabout whocansufferfromEDs

•Appropriatelength

•Entertainingandinformative

•Storyisrelatableandbelievable

•Motivatestoseekhelpifsuffering fromanED

•Unfamiliarwiththeword‘‘atracón’’ (Spanishtranslationofbingeeating)

•Includeddeﬁnitionsof EDsintheinformation sheet

Males •Aestheticallypleasing •SendsmessagethatEDscanhappento anyone

•Perfectlengthfortopicathand

•Moreinformationonconsequencesof EDsisneeded

•Changingthetitleofthefotonovelato somethingmorealarmingmightattract moreLatinmentoreadit

•Addedmorematerial totheinformationsheet

•Changedtitleto somethingmoreurgent soastograbthe attentionofLatinomen

Adolescents

Females •Visuallypleasing

•Fotonovelaismore attractiveandinvitingthan aregularbrochure

•Storyisbelievable

•FamilydynamicisrelatabletoLatin homes

•Lengthofstoryisgood,nottoolongor short

•Bringsawarenesstothepossible consequencesofEDs

•DifferenttypesofEDsarenotdeﬁned wellenoughtodifferentiatebetween them

•AddingEnglishandmakingitSpanglish ismorerepresentativeofLatinateenlife

•Weaddeddeﬁnitions ofEDsonthe

informationsheet

•Changedscriptfrom SpanishtoSpanglish, withEnglishusedwith peersandSpanishat home

Males •Graphicsareattractive

•Wouldchoosefotonovela overabrochure

•Comicbook/animation feelismoreentertaining ratherthanovertlyrealistic likewithpictures

•Informativebutnotboring

•Storyisrealistic

•Fotonovelaisnottoocomplexforthe intendedage-group

•Lengthofbookisgreat

•Arrowsornumbersmightbehelpfulto followalongwiththestoryline

•Gradualdetailededits madeiteasiertofollow scriptwithouttheneed ofnumbers.

está escrito, nollama la atención.’’ [...even more when thereare just words, when all is written, don’t grab the attention].

In terms of thecontent, theparticipants felt that the

fotonovelacoveredmostoftheimportantinformationabout EDsandthatitwaseasyforthemtoself-identifywiththe story.Forexample,oneoftheparticipantsmentioned‘‘está bastanteclaroyeste,dejabienidentiﬁcadocomoloquees bulimia,eltemaquesetrató,queavecesconfundoesoy estábienclarotodo’’[itisquiteclearanditiswellidentiﬁed likewhatbulimiais,thetopicthatwasdiscussedthat, some-timesIgetitconfused,andeverythingisclear].However, oneparticipantexpressedconcernthatthemaincharacter wasabitoverweightwhich,couldbemisleading, consider-ingthat peoplewithdifferentbodytypes cansuffer from an ED. She said‘‘Enmi opinión,la que está sufriendo el

problemase veunpoco gorditaenla foto. Normalmente cuandotieneneseproblema,avecesnoestánasíde gor-das,nocomolopintalafoto,estánenunpesonormal,más queellas,psicológicamentesevenconmássobrepeso,eso esloqueyopienso.’’[Inmyopinion,whoissufferingthe problemlooksalittlebitfatinthegraphic.Usually,when theyhavethatproblem,sometimestheyarenotfatlikein thephoto,theyareinanormalweight,butpsychologically, theyarelookingthemselvesmoreoverweight,thatiswhat Ithink].Finally,oneparticipantmentionedthatthe differ-encesbetweenEDswerenotfullyexplainedordevelopedin thefotonovelastory.

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fotonovela)practicallytous,theLatinos,anditisthe real-itywhenwehavefootballgames].Anotherparticipantsaid ‘‘unaformasencilladedarinformación,sindarnoscuenta’’

[itisasimplewayofgiveusinformation,withoutrealizing it].Theythoughtthathavingthefotonovelawrittenin Span-ishwasappropriateforthetargetgroup,andthatthestory accuratelyreﬂects theLatino’shabitsandculture. Never-theless,theadultmalegroupparticipantsdidnotﬁndthe titleappealing.Oneoftheparticipantsmentioned‘‘Pienso queparallamarlaatenciónenloslatinos,sientoyo,que deberíaponerleenfoqueaconsecuenciasquetieneelcomer sindarsecuenta,o comer descontroladamente,qué eslo quepuedepasar...enfermedades.’’[Ithinkthat tograbs the attention of Latinos, I feel that, it should put more emphasisonconsequences ofeatingunwittingly or eating outofcontrol,whatcouldhappen...illnesses].Another par-ticipantsaid‘‘untítuloquenosllevaraapensarunpoquito’’

[atitlethatmakesustothinkalittlebit].Theysuggested forthetitletofocusonthehealthconsequencesofEDsin ordertocatchattentionandthereforeencouragemalesto readthestory.

Editingprocessandﬁnalversions

The feedback from all participants was discussed by the research team and consensus was reached about the changestobeincorporatedineachfotonovela.Intheadult

fotonovelas, most of the edits were made in the male version. The original title was ‘‘José y sus retos con la comida’’[José andhischallengeswithfood]andbasedon participants’feedbackwaschangedto‘‘Josémanejandolas consecuenciasdenocomersaludablemente’’[Josédealing withthe consequences of not eating healthy]. In both of the adult versions, we modified the information sheet at the end of the story to clarify the differences between the different EDs. Following participant feedback, in the adolescentfemaleversion,theuseofSpanglishwasadded across the dialogue among peers and the use of Spanish waskeptwithinthedialoguewithparentstobetterreflect therealityofLatinofamilieswithdifferentlevelsof accul-turation. In both adolescent versions (female and male) theinformationsheetwasmodifiedin thesamewayasin theadultversions.Inordertohavepolishedfinalproducts, severalretouchesandfinaldetailededitsweremadetothe artgraphics in all fourversions of the fotonovelas. Final

fotonovelas full script versions are available through the university web page link http://www.med.unc. edu/psych/eatingdisorders/Learn More/informacion-en-espanol/fotonovelas).

Discussion

Wedeveloped fotonovelas toeducatethe adolescentand adultLatinopopulationsaboutEDs.Basedonthereceptivity thatwefoundinthisstudy,thefotonovelaappearstobea culturallysensitiveavenuetoeducateandraiseawareness aboutEDsamongLatinosintheUnitedStates.Tothebestof ourknowledge,thefotonovelaswedevelopedaretheﬁrst culturallysensitive psychoeducationalmaterials aboutEDs thataredirectedtoLatinosintheUnitedStates.

Currently,traditionalEDeducativematerials inSpanish (i.e.,brochures,pamphlets)arenotculturallytailoredfor Latinos. Psychoeducational materials that are culturally competent for a specific population could enhance the educative process (Unger et al., 2013) and treatment outcomes (Miranda et al., 2005). Furthermore, a study that explored Latinos’ connections to communication channelsforhealthgoalsintheUnitedStatesfoundstrong connectionsofLatinos toethnicmediaversus mainstream media (Wilkin & Ball-Rokeach, 2006). In our study, parti-cipants mentioned that they were more prompt to read the fotonovelas because they were ‘‘eye catching’’ and because they could relate to the story. In contrast, they did not find traditional brochures with only text ‘‘eye catching’’ or something they could relate to. Having materials that catch the attention of the population that they are intended to educate, therefore motivating the potential reader to engage with the psychoeducational material is an initialand important stepin theeducation andawareness process.Also,theself-identificationof the readerswiththestoryorwiththecharacterscouldhavean impactinreducingstigma,whichisabarrierthathasbeen associatedwithseekingcarefor EDs(Beckeretal.,2010), especiallyintheLatinopopulation(Reyes-Rodríguezetal., 2013). If an individual self-identifies with a character in a story, theymight be more likelyto view the character in the story as a role model, which would increase the changesoftheindividualengaginginthetargetedbehaviour changes(Hernandez&Organista,2013).Otherstudiesusing fotonovelas for health literacy have demonstrated their effectivenessascomparedwithtraditionaleducative mate-rials, specifically with the Latino population (Hernandez & Organista, 2013; Unger et al., 2013). Future research shouldtesttheeffectivenessofourfourfotonovelascripts. Thisstudy hassomelimitations.This wasalowbudget studywithanallottedone-yearperiodforcompletion.Due totimeconstraints,itwasnotpossibletorecruitmoremale participants,especiallyadolescents,inordertoobtainmore feedback.Anotherlimitationofthestudywasourinability to develop more than one script for each group, limiting thepossibilitytoportraydiversescenariosinwhichEDscan occur.Forexample,thefactthatEDsoccurinpeoplewith differentbodyshapesisimpossibletorepresentinasingle story.Differentscriptsshouldbedevelopedinorderto cap-turethewiderangeofpossibilitiesinwhichLatinos/ascan beaffectedbyEDs.Despitetheselimitations,thecreation ofthesefourfotonovelasisanimportantfirststeptowards providing a culturally competent intervention to educate andraiseawarenessaboutEDsamongLatinosintheUnited States.

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Ethical

disclosures

Protection of human and animal subjects.The authors declarethatnoexperimentswereperformedonhumansor animalsforthisstudy.

Conﬁdentialityofdata.Theauthorsdeclarethatnopatient dataappearinthisarticle.

Right to privacy and informed consent.The authors declarethatnopatientdataappearinthisarticle.

Conﬂict

of

interest

Theauthorsdeclarenoconﬂictofinterest.

Acknowledgements

This researchwassupported by IBM Junior Faculty Devel-opmentAwardandNIMHgrant(K-23-MH087954)toMLRat theUniversityofNorthCarolinaatChapelHill.Dr.Bulikisa grantrecipientfromShireandacknowledgesfundingfrom theSwedishResearchCouncil(VRDnr:538-2013-8864).The NIMHhadnofurtherroleinstudydesign;incollection; anal-ysisandinterpretationofdata;inthewritingofthereport; andinthedecisiontosubmitthepaperforpublication.We expressourgratitudetoallparticipantsinthisresearch.

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