# A Bifactor Measure of Societal Stigma Toward Eating Disorders and Obesity: Scale Development and Validation

## TL;DR

This study develops a reliable tool to measure societal stigma toward eating disorders and obesity in Spain, highlighting its public health importance.

## Contribution

The study introduces a validated, multidimensional stigma measure tailored for Spanish-speaking populations, integrating modern stigma frameworks.

## Key findings

- The 36-item instrument showed excellent psychometric properties and a strong general stigma factor.
- Stigma was higher among men, older individuals, and those without personal or familial experience of eating disorders or obesity.
- The bifactor model demonstrated excellent fit, supporting the tool's reliability for large-scale research.

## Abstract

Public health relevance—How does this work relate to a public health issue?
Societal stigma toward eating disorders and obesity is a modifiable public health risk factor linked to psychological distress, reduced help-seeking, and social and healthcare inequalities.By documenting the structure and distribution of stigma in a Spanish-speaking population, this study situates stigma as a population-level issue relevant to prevention, early detection, and health equity.

Societal stigma toward eating disorders and obesity is a modifiable public health risk factor linked to psychological distress, reduced help-seeking, and social and healthcare inequalities.

By documenting the structure and distribution of stigma in a Spanish-speaking population, this study situates stigma as a population-level issue relevant to prevention, early detection, and health equity.

Public health significance—Why is this work of significance to public health?
The study advances public health measurement by integrating contemporary stigma frameworks into a psychometrically robust instrument suitable for large-scale population research.Evidence on how stigma varies by age, gender, and experiential factors strengthens the scientific basis for understanding stigma as a social determinant of health.

The study advances public health measurement by integrating contemporary stigma frameworks into a psychometrically robust instrument suitable for large-scale population research.

Evidence on how stigma varies by age, gender, and experiential factors strengthens the scientific basis for understanding stigma as a social determinant of health.

Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health?
Findings support the inclusion of stigma assessments in public health surveillance and evaluation of prevention and health promotion strategies related to eating disorders and obesity.Public health actions should move beyond individual responsibility narratives and address stigma through structural, educational, and media-level interventions that promote compassionate and equitable care.

Findings support the inclusion of stigma assessments in public health surveillance and evaluation of prevention and health promotion strategies related to eating disorders and obesity.

Public health actions should move beyond individual responsibility narratives and address stigma through structural, educational, and media-level interventions that promote compassionate and equitable care.

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—particularly in Spanish-speaking populations—are 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 (ωh = 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.