{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T14:00:20Z","timestamp":1774274420656,"version":"3.50.1"},"reference-count":37,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,3,20]],"date-time":"2026-03-20T00:00:00Z","timestamp":1773964800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Background: Societal stigma toward eating disorders and obesity remains pervasive and is associated with psychological distress, maladaptive eating behaviors, reduced help-seeking, and barriers to care. Despite its documented impact, comprehensive and psychometrically robust instruments to assess stigma\u2014particularly in Spanish-speaking populations\u2014are scarce. This study aimed to develop and validate a multidimensional measure of societal stigma toward eating disorders and obesity in Spain, grounded in contemporary stigma frameworks. Methods: A cross-sectional observational study was conducted in a large community sample recruited online (N = 2121). An initial pool of stigma-related items was developed based on theoretical and empirical literature and refined through expert content validation. Psychometric evaluation included item screening, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), bifactor modeling, and reliability assessment. The sample was randomly split for EFA (n = 988) and CFA (n = 658). Associations between stigma scores and sociodemographic and experiential variables were examined. Results: The final 36-item instrument demonstrated excellent psychometric properties. Bifactor analyses supported an essentially unidimensional structure dominated by a strong general stigma factor, with secondary content-specific dimensions (e.g., legitimacy, personal responsibility, visibility, and treatment beliefs). The theory-driven bifactor model showed excellent fit (CFI = 0.991; TLI = 0.990; RMSEA = 0.024). The general factor exhibited high reliability (\u03c9h = 0.87). Higher stigma was observed among men, older participants, and individuals without personal or familial experience of eating disorders or obesity. Conclusions: This study provides a reliable and theoretically grounded instrument for assessing societal stigma toward eating disorders and obesity in Spain. The scale enables systematic research on stigma and offers a valuable tool for public health surveillance, intervention development, and evaluation of anti-stigma initiatives aimed at promoting compassionate and equitable care.<\/jats:p>","DOI":"10.3390\/ijerph23030399","type":"journal-article","created":{"date-parts":[[2026,3,20]],"date-time":"2026-03-20T17:02:43Z","timestamp":1774026163000},"page":"399","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["A Bifactor Measure of Societal Stigma Toward Eating Disorders and Obesity: Scale Development and Validation"],"prefix":"10.3390","volume":"23","author":[{"given":"Carlos","family":"Suso-Ribera","sequence":"first","affiliation":[{"name":"Rheumatology Research Group, Vall d\u2019Hebron Research Institute, 08035 Barcelona, Spain"},{"name":"Faculty of Health Sciences, Universidad Europea de Canarias, 38300 La Orotava, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Laura","family":"D\u00edaz-Sanahuja","sequence":"additional","affiliation":[{"name":"Faculty of Psychology and Speech Therapy, Universidad de Valencia, 46010 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Macarena","family":"Paredes-Mealla","sequence":"additional","affiliation":[{"name":"Hospital Provincial Foundation, 12006 Castellon, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sara","family":"Marsal","sequence":"additional","affiliation":[{"name":"Rheumatology Research Group, Vall d\u2019Hebron Research Institute, 08035 Barcelona, Spain"},{"name":"Department of Rheumatology, Hospital Universitari Vall d\u2019Hebron, 08035 Barcelona, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4874-8013","authenticated-orcid":false,"given":"Miriam","family":"Almirall","sequence":"additional","affiliation":[{"name":"Rheumatology Research Group, Vall d\u2019Hebron Research Institute, 08035 Barcelona, Spain"},{"name":"Department of Rheumatology, Hospital Universitari Vall d\u2019Hebron, 08035 Barcelona, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,20]]},"reference":[{"key":"ref_1","first-page":"1800","article-title":"Moralities in Food and Health Research","volume":"30","author":"Askegaard","year":"2014","journal-title":"J. Mark. Manag."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"102558","DOI":"10.1016\/j.wsif.2021.102558","article-title":"Demystifying \u2018Diet Culture\u2019: Exploring the Meaning of Diet Culture in Online \u2018Anti-Diet\u2019 Feminist, Fat Activist, and Health Professional Communities","volume":"90","author":"Jovanovski","year":"2022","journal-title":"Womens Stud. Int. Forum"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Merino, M., Tornero-Aguilera, J.F., Rubio-Zarapuz, A., Villanueva-Tobaldo, C.V., Mart\u00edn-Rodr\u00edguez, A., and Clemente-Su\u00e1rez, V.J. (2024). Body Perceptions and Psychological Well-Being: A Review of the Impact of Social Media and Physical Measurements on Self-Esteem and Mental Health with a Focus on Body Image Satisfaction and Its Relationship with Cultural and Gender Factors. Healthcare, 12.","DOI":"10.3390\/healthcare12141396"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"755","DOI":"10.1016\/j.jneb.2023.08.001","article-title":"TikTok Promotes Diet Culture and Negative Body Image Rhetoric: A Content Analysis","volume":"55","author":"Raiter","year":"2023","journal-title":"J. Nutr. Educ. Behav."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Brelet, L., Flaudias, V., D\u00e9sert, M., Guillaume, S., Llorca, P.-M., and Boirie, Y. (2021). Stigmatization toward People with Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder: A Scoping Review. Nutrients, 13.","DOI":"10.3390\/nu13082834"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e13642","DOI":"10.1111\/obr.13642","article-title":"Changing the Global Obesity Narrative to Recognize and Reduce Weight Stigma: A Position Statement from the World Obesity Federation","volume":"25","author":"Nutter","year":"2024","journal-title":"Obes. Rev."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1186\/s40337-024-01128-3","article-title":"Perceived Clinician Stigma and Its Impact on Eating Disorder Treatment Experiences: A Systematic Review of the Lived Experience Literature","volume":"12","author":"Lubieniecki","year":"2024","journal-title":"J. Eat. Disord."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"454","DOI":"10.1080\/09638237.2019.1685081","article-title":"How Do People with Eating Disorders Experience the Stigma Associated with Their Condition? A Mixed-Methods Systematic Review","volume":"30","author":"McNamara","year":"2021","journal-title":"J Ment Health"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"101678","DOI":"10.1016\/j.bodyim.2023.101678","article-title":"A Systematic Review of Weight Stigma and Disordered Eating Cognitions and Behaviors","volume":"48","author":"Levinson","year":"2024","journal-title":"Body Image"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Feldhege, J., Bilic, S., Ali, K., Fassnacht, D.B., Moessner, M., Farrer, L.M., Griffiths, K.M., and Bauer, S. (2022). Knowledge and Myths about Eating Disorders in a German Adolescent Sample: A Preliminary Investigation. Int. J. Environ. Res. Public. Health, 19.","DOI":"10.3390\/ijerph19116861"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1037\/sah0000104","article-title":"Conceptualizing and Measuring Mental Illness Stigma: The Mental Illness Stigma Framework and Critical Review of Measures","volume":"3","author":"Fox","year":"2018","journal-title":"Stigma Health"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Stangl, A.L., Earnshaw, V.A., Logie, C.H., Van Brakel, W., C. Simbayi, L., Barr\u00e9, I., and Dovidio, J.F. (2019). The Health Stigma and Discrimination Framework: A Global, Crosscutting Framework to Inform Research, Intervention Development, and Policy on Health-Related Stigmas. BMC Med., 17.","DOI":"10.1186\/s12916-019-1271-3"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Bray, B., Bray, C., Bradley, R., and Zwickey, H. (2022). Binge Eating Disorder Is a Social Justice Issue: A Cross-Sectional Mixed-Methods Study of Binge Eating Disorder Experts\u2019 Opinions. Int. J. Environ. Res. Public. Health, 19.","DOI":"10.3390\/ijerph19106243"},{"key":"ref_14","first-page":"8","article-title":"Characterization, Epidemiology and Trends of Eating Disorders","volume":"39","author":"Canals","year":"2022","journal-title":"Nutr. Hosp."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Ben\u00edtez Brito, N., Moreno Redondo, F., Pinto Robayna, B., De Las Heras Roge, J., Ramallo Fari\u00f1a, Y., and Diaz Romero, C. (2024). A Scoping Review of the Prevalence of Eating Disorders in Spain. Nutrients, 16.","DOI":"10.3390\/nu16101513"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"542","DOI":"10.1017\/S1138741600004546","article-title":"Comparison of Single- and Double-Stage Designs in the Prevalence Estimation of Eating Disorders in Community Samples","volume":"11","author":"Labrador","year":"2008","journal-title":"Span. J. Psychol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1016\/j.psychres.2015.02.015","article-title":"Prevalence and Comorbidity of Eating Disorders among a Community Sample of Adolescents: 2-Year Follow-Up","volume":"227","author":"Arribas","year":"2015","journal-title":"Psychiatry Res."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Guti\u00e9rrez-Gonz\u00e1lez, E., Garc\u00eda-Solano, M., Pastor-Barriuso, R., Fern\u00e1ndez De Larrea-Baz, N., Roll\u00e1n-Gordo, A., Pe\u00f1alver-Arg\u00fceso, B., Pe\u00f1a-Rey, I., Poll\u00e1n, M., P\u00e9rez-G\u00f3mez, B., and the ENE-COVID Study Group (2023). Socio-Geographical Disparities of Obesity and Excess Weight in Adults in Spain: Insights from the ENE-COVID Study. Front. Public Health, 11.","DOI":"10.3389\/fpubh.2023.1195249"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"361","DOI":"10.1016\/j.molmed.2024.02.007","article-title":"Eating Disorders and Obesity: Bridging Clinical, Neurobiological, and Therapeutic Perspectives","volume":"30","author":"Giel","year":"2024","journal-title":"Trends Mol. Med."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Da Luz, F.Q., Hay, P., Touyz, S., and Sainsbury, A. (2018). Obesity with Comorbid Eating Disorders: Associated Health Risks and Treatment Approaches. Nutrients, 10.","DOI":"10.3390\/nu10070829"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1017\/S1121189X00000956","article-title":"Eating Disorders and Obesity: Two Sides of the Same Coin?","volume":"18","author":"Day","year":"2009","journal-title":"Epidemiol. Psichiatr. Sci."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1375","DOI":"10.1038\/npp.2016.269","article-title":"Pathological Overeating: Emerging Evidence for a Compulsivity Construct","volume":"42","author":"Moore","year":"2017","journal-title":"Neuropsychopharmacology"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Obeid, N., Flament, M.F., Buchholz, A., Henderson, K.A., Schubert, N., Tasca, G., Thai, H., and Goldfield, G. (2022). Examining Shared Pathways for Eating Disorders and Obesity in a Community Sample of Adolescents: The REAL Study. Front. Psychol., 13.","DOI":"10.3389\/fpsyg.2022.805596"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"126","DOI":"10.1186\/s40337-024-01086-w","article-title":"Understanding Stigma in the Context of Help-Seeking for Eating Disorders","volume":"12","author":"Wall","year":"2024","journal-title":"J. Eat. Disord."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Boateng, G.O., Neilands, T.B., Frongillo, E.A., Melgar-Qui\u00f1onez, H.R., and Young, S.L. (2018). Best Practices for Developing and Validating Scales for Health, Social, and Behavioral Research: A Primer. Front. Public Health, 6.","DOI":"10.3389\/fpubh.2018.00149"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"358","DOI":"10.1186\/s12939-025-02702-0","article-title":"Overlooked and Undertreated: Gendered Ageism in Primary Care Management of Eating Disorders","volume":"24","author":"Kohestani","year":"2025","journal-title":"Int. J. Equity Health"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"492","DOI":"10.1080\/10640266.2024.2380185","article-title":"Weight Stereotypes in Eating Disorder Recognition","volume":"33","author":"Kressel","year":"2025","journal-title":"Eat. Disord."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1186\/s40337-023-00752-9","article-title":"It\u2019s Not All about Control: Challenging Mainstream Framing of Eating Disorders","volume":"11","author":"Talbot","year":"2023","journal-title":"J. Eat. Disord."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"941","DOI":"10.1038\/oby.2008.636","article-title":"The Stigma of Obesity: A Review and Update","volume":"17","author":"Puhl","year":"2009","journal-title":"Obesity"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Ainz-Galende, A., Torres-Haro, M.J., and Rodr\u00edguez-Puertas, R. (2025). Binge Eating Disorder and Fatphobia: Social Stigma, Exclusion, and the Need for a New Perspective on Health. Societies, 15.","DOI":"10.3390\/soc15050115"},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Muse, M.D. (2017). Eating Disorders: Evidence-Based Integrated Biopsychosocial Treatment of Anorexia Nervosa, Bulimia and Binge Eating Disorder. Cognitive Behavioral Psychopharmacology, Wiley. [1st ed.].","DOI":"10.1002\/9781119152606.ch6"},{"key":"ref_32","unstructured":"(2026, March 17). World Health Organization Nutrition Landscape Information System (NLiS): Moderate and Severe Thinness, Underweight, Overweight, Obesity. Available online: https:\/\/apps.who.int\/nutrition\/landscape\/help.aspx?menu=0&helpid=420."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1027","DOI":"10.1016\/S0140-6736(23)02750-2","article-title":"Worldwide Trends in Underweight and Obesity from 1990 to 2022: A Pooled Analysis of 3663 Population-Representative Studies with 222 Million Children, Adolescents, and Adults","volume":"403","author":"Phelps","year":"2024","journal-title":"The Lancet"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Cohen, L., Manion, L., and Morrison, K. (2007). Research Methods in Education, Routledge. [6th ed.].","DOI":"10.4324\/9780203029053"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1186\/s12955-023-02188-w","article-title":"Scale Agreement, Ceiling and Floor Effects, Construct Validity, and Relative Efficiency of the PROPr and EQ-5D-3L in Low Back Pain Patients","volume":"21","author":"Klapproth","year":"2023","journal-title":"Health Qual. Life Outcomes"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Molnar, M.G., Snaychuk, L.A., and Cassin, S.E. (2025). What Is the Effect of Attributing Disordered Eating Behaviours to Food Addiction Versus Binge Eating Disorder? An Experimental Study Comparing the Impact on Weight-Based and Mental Illness Stigma. Nutrients, 17.","DOI":"10.3390\/nu17132217"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"929","DOI":"10.32604\/ijmhp.2025.065646","article-title":"Unpacking Societal Stigma toward Schizophrenia: Development of a Multidimensional Scale with Sociodemographic Insights","volume":"27","year":"2025","journal-title":"Int. J. Ment. Health Promot."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/3\/399\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T13:08:38Z","timestamp":1774271318000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/3\/399"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,20]]},"references-count":37,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["ijerph23030399"],"URL":"https:\/\/doi.org\/10.3390\/ijerph23030399","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,20]]}}}