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

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.

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.

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 (ω_h = 0.87). Higher stigma was observed among men, older participants, and individuals without personal or familial experience of eating disorders or obesity.

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.