International Journal of Environmental Research and Public Health Article Translation, Cross-Cultural Adaptation, and Psychometric Validation of the Positive Body Image among Adolescents Scale (PBIAS) into Spanish and Catalan Glòria Tort-Nasarre 1,2,3 , Eva Artigues-Barberà 4,5 , Mercè Pollina-Pocallet 5,6 , Anna Espart 2,7,8, * , Judith Roca 2,8 and Josep Vidal-Alaball 5,9,10 1 SAP ANOIA, Gerència Territorial Catalunya Central, Institut Català de la Salut (ICS), 08700 Igualada, Spain 2 Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida, 25198 Lleida, Spain 3 AFIN, Research Group and Outreach Centre, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain 4 Balàfia Primary Care Center, Gerència Territorial Lleida, Institut Català de la Salut (ICS), 25005 Lleida, Spain 5 Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08007 Barcelona, Spain 6 Bellpuig Primary Care Center, Gerència Territorial Lleida, Institut Català de la Salut (ICS), 25250 Lleida, Spain 7 Development of Healthy and Sustentable Organizations and Territories (DOTSS), Serra Húnter Lecturer, 25001 Lleida, Spain 8 Research Group of Health Care (GRECS), Lleida Institute for Biomedical Research, Dr. Pifarré Foundation, IRBLleida, 25198 Lleida, Spain 9 Health Promotion in Rural Areas Research Group, Gerència Territorial de la Catalunya Central, Institut Català de la Salut (ICS), 08272 Sant Fruitós del Bages, Spain 10 Department of Medicine, University of Vic-Central University of Catalonia, 08500 Vic, Spain * Correspondence: anna.espart@udl.cat Abstract: The Positive Body Image among Adolescents Scale (PBIAS) explores the factors that bolster and interfere with developing and maintaining a positive body image during adolescence. The Citation: Tort-Nasarre, G.; aim of this study was to translate, adapt, and validate the PBIAS into Spanish and Catalan. A Artigues-Barberà, E.; Pollina-Pocallet, cross-sectional study was conducted for the instrument’s translation, cross-cultural adaptation, and M.; Espart, A.; Roca, J.; Vidal-Alaball, psychometric validation. A process of translation, back-translation, expert consultation, and piloting J. Translation, Cross-Cultural Adaptation, and Psychometric was followed. The reliability and statistical validity were evaluated. The Cronbach’s alpha was 0.95 in Validation of the Positive Body Image both the Spanish and Catalan versions. Pearson’s correlation coefficients were statistically significant among Adolescents Scale (PBIAS) (r > 0.087) for all items analyzed. The resulting values of the Spanish and Catalan versions indicate into Spanish and Catalan. Int. J. a good level of concordance (p < 0.001) with the original questionnaire, the comparative fit index Environ. Res. Public Health 2023, 20, being 0.914 and 0.913, the Tucker–Lewis index being 0.893 and 0.892, the root mean square error 4017. https://doi.org/10.3390/ of approximation being 1.31 and 1.28, and the standardized root mean square residual being 0.051 ijerph20054017 and 0.060, respectively. The instrument presents a good level of internal consistency, a high level of Academic Editor: Jiun-Hau Huang reliability, and statistical validity compared to the original instrument. The PBIAS in Spanish and Catalan can be a useful assessment instrument for educators and health professionals in the context Received: 16 January 2023 of adolescent mental health literacy. This work contributes to the Sustainable Development Goals Revised: 17 February 2023 (Goal 3) of the United Nations 2030 Agenda. Accepted: 20 February 2023 Published: 23 February 2023 Keywords: body image; adolescents; adolescent mental health; psychometrics; instrument validation; cross-cultural adaptation Copyright: © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article 1. Introduction distributed under the terms and Body image is a multifaceted construct that encompasses affective, cognitive, percep- conditions of the Creative Commons tual, and behavioral aspects related to one’s body and appearance [1]. The body image Attribution (CC BY) license (https:// construct has multiple meanings among adolescents and a mismatch between actual and creativecommons.org/licenses/by/ desired body image does not necessarily imply dissatisfaction [2]. However, several health 4.0/). Int. J. Environ. Res. Public Health 2023, 20, 4017. https://doi.org/10.3390/ijerph20054017 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2023, 20, 4017 2 of 11 correlates and consequences of having a negative body image, e.g., depression, anxiety, low self-esteem, substance abuse, unhealthy weight control practices, and disordered eating [3–6], and a positive body image, e.g., health-promoting behaviors and greater well-being [7,8], have been established. Adolescence is a period of both physical and emotional change that involves an adjustment of the perception of the person as an independent individual who makes his or her own decisions. The different developmental processes that characterize adolescence could affect the positive experiences of one’s body image [9]. Sometimes, experiences and self-perception can lead to emotional distortions that affect mental health. A maladjusted perception of body self-image may contribute to the development of significant mental health problems [10]. During adolescence, this perception is closely related to body weight and gender [11,12]. Therefore, the formation of positive body attitudes and perceptions during adolescence would be considered essential. In recent years, research focused on positive body image and its links to well-being has been carried out [13]. According to Tylka and Wood-Barcalow, a positive body image is defined as an individual’s love, respect, acceptance, and appreciation of and comfort with their body, regardless of their actual physical appearance, as well as their ability to interpret messages in a body-protective manner [14]. However, this conceptualization was generated from adult research findings and does not include factors that are unique to the developmental context of adolescents [15]. During the process of change and acceptance of one’s own body image, which involves the transition from childhood to adolescence and then to adulthood, school nurses play a key role. The early detection of disturbances in mental well-being, which often accompany disorders in the acceptance of self-image, are often identified for the first time by educators and health professionals, such as school nurses [16,17]. Adolescent mental health literacy, as a part of health education, is a critical element for health professionals such as school nurses working with this population group [18], as well as other health professionals such as psychologists or pediatricians. Although there are tools to assess emotional and mental well-being in adolescents, the range of tools available to assess body image and emotional well-being specifically in adolescents and in different languages is not particularly extensive. Often these tools are designed for culturally and linguistically different populations rather than those we wish to assess. Some of the instruments used to assess positive body image among adults cited in Maes’ study [9] are, for example, scales based on self-care such as the Body Responsiveness Questionnaire (BRQ) [19] or the Mindful Self-Care Scale (MSCS) [20]; scales based on the appreciation of the body such as the Body Appreciation Scale-2 (BAS-2) [21]; or scales based on self-acceptance, such as the Body Image Coping Strategies Inventory (BCSI) [22]. In this regard, the Positive Body Image among Adolescents Scale (PBIAS) developed by Maes et al. measures the construct of a positive body image among adolescents. The PBIAS is a questionnaire validated in 2021, consisting of fifteen items grouped into four factors. Factor 1 includes questions about the adolescent’s own body appreciation; Factor 2 includes questions about others’ body esteem; Factor 3 includes questions about the adolescent’s resilience to the body’s ideal appreciation in the media; and Factor 4 includes questions about the adolescent’s resilience to negative comments about their appearance. Each dimension shares similarities with conceptualizations based on body image during adulthood but is described more in the context of adolescent development. In addition, the PBIAS is different in the sense that it encompasses, in a single scale, components that had been studied separately, with the following four subscales: appreciation of one’s own body, appreciation of other people’s bodies, resilience to body ideals in the media, and resilience to negative feedback on appearance [9]. The PBIAS may be useful for a significant group of professionals and for researchers who wish to explore the factors that may bolster and interfere with developing and main- taining a positive body image during adolescence [9]. Similarly, it may be useful for Int. J. Environ. Res. Public Health 2023, 20, 4017 3 of 11 clinicians and educators in their endeavors to help adolescents develop and maintain a positive body image. Thus, the main objective of the study was to describe the process of translating, culturally adapting, and validating the PBIAS in order to assess a positive body image in the Spanish and Catalan context. A secondary objective is to provide a new tool adapted to Spanish- or Catalan-speaking educators and health professionals to assess body image disturbances in adolescents. 2. Materials and Methods 2.1. Study Design The design of the study was carried out in two phases. The first phase involved transla- tion and cultural adaptation, a process that required verification of the metric properties of the Spanish and Catalan languages. In the second phase, a cross-sectional analytical design was used to analyse the cross-cultural adaptation, validation, and reliability assessment of the instrument, using Cronbach’s alpha for internal consistency and confirmatory factor analysis (CFA) to assess factorial validity. 2.2. Participants A convenience sample of 222 participants was selected from a reference population of adolescents. The adolescents were selected from three secondary schools in Catalonia (Spain) in the cities of Capellades, Calaf, and Lleida. The sample size was based on a person–item ratio of at least 10 subjects per item in the instrument for general psychometric approaches: scale and item analysis, Pearson’s correlations, and exploratory factor analysis [23]. The inclusion criteria were being a secondary school student, being aged between 12 and 18 years, and voluntary participation. No exclusion criteria other than not meeting the eligibility criteria were considered. 2.3. Variables and Procedures First, permission to translate the PBIAS into Spanish and Catalan and then culturally adapt and validate its content was obtained from the main author of the original instru- ment [9]. As the original, the scale has fifteen Likert-type items with seven possible response options: (1) completely disagree; (2) strongly disagree; (3) rather disagree; (4) neither agree nor disagree; (5) rather agree; (6) strongly agree; and (7) completely agree. The PBIAS was tested on Belgium adolescents for validity and reliability with strong consistency (with comparative fit index (CIF) = 0.913, Tucker–Lewis index (TLI) = 0.892, root mean square error of approximation (RMSEA) = 1.28, and standardized root mean square residual (SRMR) = 0.060), and was translated from Dutch into English to provide an option for English-speaking countries [9]. The English version of the questionnaire was translated into Spanish and Catalan and adapted to the cultural context. To ensure the credibility of the translation, we have tried to keep as close as possible to the original English text. However, a direct translation was not possible because some words had to be changed to match the Spanish and Catalan language and context. The recommendations for a transcription process outlined by the World Health Organization [24] and the recommendations of Sousa et al. [23] were followed. Two translators, bilingual in Spanish and Catalan and proficient in English, one of them an expert in health terminology and the other in linguistics, participated independently in the translation and back-translation. Two expert reviewers and three adolescents were also asked to verify the clarity and comprehension of the instrument. Based on suggestions to improve its comprehensibility, the instrument was subsequently piloted on 20 adolescents, who did not suggest any changes. Once this process was completed, the final version was approved. Sociodemographic data were provided for the study: school grade (1st to 4th secondary education and ESO in the Spanish educational system), age (12 to 18 years old), gender Int. J. Environ. Res. Public Health 2023, 20, 4017 4 of 11 (female, male, and non-binary), weight (kg), height, (cm), and whether they had suffered or were suffering from any eating disorder (yes, no, and I am not sure). 2.4. Data Collection Data were collected between May and June 2022. The questionnaire used in this study was created online with Microsoft Forms® (Microsoft Corporation, Redmond, WA, USA). The questionnaire link (https://www.microsoft.com/en-us/microsoft-365/online-surveys- polls-quizz, accessed on 7 January 2023) was sent to the school’s teaching coordinator, who forwarded it to the students through the school’s internal platform. Students answered the questionnaire during a normal lesson to ensure high participation. Students were asked to complete the questionnaire first in Spanish and then, without leaving the online platform, to complete the same questionnaire in Catalan. The estimated time to answer the entire questionnaire was 15 min. Responses were also received through Microsoft Forms® . 2.5. Ethical Considerations The study was approved by the University Institute for Research in Primary Care (IDIAP) Jordi Gol i Gurina ethics committee (Code 21/295-P). Consent was requested from participants over 15 years of age and, from minors, consent was requested from their mother, father, or legal guardian, in compliance with the European Data Protection Regulation 2016/679 of the European Parliament and of the Council of 27 April 2016, and the Organic Law 3/2018 of 5 December, on the protection of personal data and guarantee of digital rights. Data confidentiality and anonymity were ensured throughout the process by assigning each participant an alpha-numeric code. 2.6. Data Analysis A descriptive analysis was performed to characterize the participants in the study. Continuous data were described by means and standard deviations (i.e., years, weight, and height); while categorical data were described as frequencies and percentages (i.e., years, grade, gender, and eating disorder status). After this analysis, a set of tests was carried out to assess the internal consistency and validity, and to confirm the best-structured model of factor dimensions. Following a similar methodology used by other authors [25,26], the internal consis- tency was measured through a Cronbach’s alpha analysis, and CFA was performed to assess factor validity. A principal component analysis (PCA) was carried out to deter- mine the factor structure of the instrument in the cross-cultural version in Spanish and Catalan. For this purpose, varimax was performed as a rotation method, Bartlett’s test of sphericity was used to check for assumptions, and the Kaiser–Meyer–Olkin (KMO) test was performed for sampling adequacy. To analyze construct validity, eigenvalues > 1 were identified and Pearson’s correlation coefficient was calculated for each scale item with the whole scale. To analyze the best model structure, fit indices were compared using CFI, TLI, RMSEA, and SRMR. The confidence level used was 95%. Jamovi version 2.2.5 (The jamovi project 2021, Sydney, Australia) was used to conduct the statistical analyses of the study. 3. Results A total of 222 students between 12 and 18 years old participated in the study (x̄ = 15.2, SD = 1.01, and mean = 15). The largest groups in the study were participants between 15 and 17 years old (72.1%), female (56.8%), and those not related to eating disorders (71.5%) (Table 1). Int. J. Environ. Res. Public Health 2023, 20, 4017 5 of 11 Table 1. Characteristics of the participants. Total Participants (N = 222) Mean SD Age (years old) 15.2 1.01 Weight (kg) 59.6 12.9 Height (cm) 166 14.3 Frequencies n % 12–14 58 26.4 Age (years) 15–17 158 72.1 >17 4 1.8 First ESO 3 1.35 Second ESO 55 24.7 School grade Third ESO 85 38.2 Fourth ESO 79 35.5 Female 126 56.8 Gender Male 88 39.6 Non-binary 8 3.6 Are you suffering/have you ever Yes 38 17.2 suffered from an eating disorder No 158 71.5 (e.g., anorexia or bulimia)? I am not sure 25 11.3 SD: standard deviation. ESO: compulsory secondary education in the Spanish educational system (Educación Secundaria Obligatoria). The overall value of internal consistency, measured using Cronbach’s alpha, was 0.951 in both the Spanish and Catalan versions, indicating a good level of internal consistency for all 15 items included in the questionnaire. The four-factor dimensions of the original instrument (i.e., appreciation of one’s own body, appreciation of other people’s bodies, resilience to body ideals in the media, and resilience to negative feedback on appearance) were also analyzed in these versions through CFA. The resulting values of the Spanish and Catalan versions indicate a good level of concordance (p < 0.001) with the English questionnaire, being the CFI 0.914 and 0.913, the TLI 0.893 and 0.892, the RMSEA 1.31 and 1.28, and the SRMR 0.051 and 0.060, respectively. Despite the values obtained for the four-factor dimensions, a PCA was conducted to find out whether a different factor dimension structure resulted in a better model. The overall KMO values were 0.917 in the Spanish version and 0.91 in the Catalan version; the Bartlett’s test of sphericity result was the same for both instruments, df = 105 and p < 0.001. Based on an eigenvalue greater than one, the best factor dimensions fit with three-factor dimensions in both versions (Table 2). The three factors explained the 80.7% and 78.7% of the cumulative variance in the Spanish and Catalan instruments, respectively (Table 3). Table 2. Principal Component Analysis of the Spanish and the Catalan versions. Spanish Version Catalan Version Components 1 2 3 1 2 3 1. I feel content with the way my body looks. 0.852 0.864 2. I love my body. 0.880 0.888 I accept all different features of my body, they make 3. 0.785 0.791 me who I am (e.g., my eyes). I feel content with the way my body has changed/is 4. changing during puberty (e.g., my breasts have 0.791 0.759 grown or my penis has grown). 5. I respect my body. 0.775 0.751 My body, what it looks like, and what it can do are 6. 0.662 0.690 all part of who I am as a person. Int. J. Environ. Res. Public Health 2023, 20, 4017 6 of 11 Table 2. Cont. Spanish Version Catalan Version Components 1 2 3 1 2 3 It is my hope that all teenagers are able to feel good 7. about the changes that happen in their bodies 0.896 0.881 during puberty. It is my hope that everyone is able to love their 8. 0.903 0.907 bodies as they are. It is my hope that everyone is able to view their 9. 0.890 0.876 bodies as a unique part of who they are as a person. If I am confronted with body ideals (e.g., slim or muscular bodies) in the media, I (would) try to 10. 0.780 0.751 distract myself by other things I like about the media. If I am confronted with body ideals (e.g., slim or 11. muscular bodies) in the media, I (would) try to 0.781 0.799 distract myself and think about something positive. If I (would) receive negative feedback on my 12. appearance (e.g., from friends), it is important not to 0.771 0.706 pay too much attention to this. If I (would) receive negative feedback on my 13. appearance (e.g., from friends), I (would) try to 0.767 0.694 forget about this. If I (would) receive negative feedback on my appearance (e.g., from friends), I (would) remind 14. 0.658 0.638 myself that those remarks are not important and that I love my body. If I (would) receive negative feedback on my 15. appearance (e.g., from friends), I (would) try to 0.750 0.741 distract myself and think about something positive. Rotation method: varimax. Assumption checks: Bartlett’s tests of sphericity and Kaiser-Meyer-Olkin (KMO) measure of sample adequacy. Number of components: based on eigenvalue >1. Table 3. Eigenvalues and cumulative variance of items (only shown for eigenvalues >1). Spanish Version Catalan Version Eigenvalue Cumulative Variance (%) Eigenvalue Cumulative Variance (%) 1 9.1376 60.9 8.875 59.2 2 1.7221 72.4 1.609 69.9 3 1.2402 80.7 1.321 78.7 In the analysis of construct validity, using Pearson’s correlation coefficient for each of the items with the whole scale, the significant values (r > 0.087; CI = 95%) were obtained for each of the items in both versions (Table 4). Table 4. Pearson’s correlation coefficients of items with whole scale score. Pearson’s Correlation of Items with Total Scale Score Spanish Version Catalan Version Item r p Value r p Value 1 0.809 <0.001 0.792 <0.001 2 0.830 <0.001 0.817 <0.001 3 0.847 <0.001 0.827 <0.001 4 0.808 <0.001 0.792 <0.001 Int. J. Environ. Res. Public Health 2023, 20, 4017 7 of 11 Table 4. Cont. Pearson’s Correlation of Items with Total Scale Score Spanish Version Catalan Version Item r p Value r p Value 5 0.877 <0.001 0.861 <0.001 6 0.827 <0.001 0.837 <0.001 7 0.714 <0.001 0.743 <0.001 8 0.693 <0.001 0.712 <0.001 9 0.634 <0.001 0.683 <0.001 10 0.702 <0.001 0.659 <0.001 11 0.747 <0.001 0.693 <0.001 12 0.788 <0.001 0.771 <0.001 13 0.761 <0.001 0.737 <0.001 14 0.807 <0.001 0.810 <0.001 15 0.820 <0.001 0.764 <0.001 Pearson’s Correlation Coefficients Spanish Version Catalan Version Item r p Value r p Value 1 0.809 <0.001 0.792 <0.001 2 0.830 <0.001 0.817 <0.001 3 0.847 <0.001 0.827 <0.001 4 0.808 <0.001 0.792 <0.001 5 0.877 <0.001 0.861 <0.001 6 0.827 <0.001 0.837 <0.001 7 0.714 <0.001 0.743 <0.001 8 0.693 <0.001 0.712 <0.001 9 0.634 <0.001 0.683 <0.001 10 0.702 <0.001 0.659 <0.001 11 0.747 <0.001 0.693 <0.001 12 0.788 <0.001 0.771 <0.001 13 0.761 <0.001 0.737 <0.001 14 0.807 <0.001 0.810 <0.001 15 0.820 <0.001 0.764 <0.001 r: Pearson’s correlation coefficient. In bold: statistically significant p value. A new CFA was conducted including only three-factor dimensions (i.e., appreciation of one’s own body, appreciation of other people’s bodies, and resilience to body ideals in the media and negative feedback on appearance). The resulting values indicated a significant (p < 0.001) but slightly poorer level of concordance compared with the four- factor dimensions regarding the CFI, TLI, RMSEA, and SRMR (Table 5). Table 5. Comparison of fit indices to determine the best model structure. Spanish Spanish Catalan Catalan Version Version Version Version (Four-Factors) (Three-Factors) (Four-Factors) (Three-Factors) CFI 0.914 0.870 0.913 0.866 TLI 0.893 0.843 0.892 0.838 RMSEA 0.131 0.158 0.128 0.156 SRMR 0.051 0.062 0.060 0.075 CFI: comparative fit index; TLI: Tucker–Lewis index; RMSEA: root mean square error of approximation; and SRMR: standardized root means square residual. 4. Discussion The aim of the study was to describe the process of translating the PBIAS into Spanish and Catalan and then perform a cross-cultural adaptation and validation of both versions. Int. J. Environ. Res. Public Health 2023, 20, 4017 8 of 11 After translation according to the main standards [23], the results of the statistical tests showed that the internal consistency of the instrument calculated with Cronbach’s alpha analysis was analogous (α = 0.951) to the original instrument [9]. The PCA measured in our work was used to assess the cross-cultural adaptation of the scales and indicated that, unlike in the original instrument [9], a possible structured model of three factorial dimensions could also fit as a good model in the Spanish and Catalan versions. In this new three-factor model, the statements included in the original factor ‘Resistance to media body ideals’ also seemed to fit into the factor ‘Resistance to negative opinions about appearance’. In this sense, items 1 to 6 of the scale would be included in factor 1 (body self-esteem), items 7 to 9 would be included in factor 2 (others’ opinions about my body), and items 10 to 15 would be included in factor 3 (resistance to negative body image ideals and feedback). However, the analysis comparing the model fit indices did not show the same result as the PCA. Despite the fact that values obtained in the comparison of the four- versus three-factor dimension model were not too different, in all indices the results were better in the four-factor dimension model, based on the fact that a good model is defined by the following values: CFI > 0.95, TLI > 0.95, RMSEA = 0.05 (or 0.08 as an acceptable model), and SRMS < 0.10. These results confirm that although cultural adaptation allows the generation of a three-factor model, the similar results between the three- and four-factor models in both cases could be comparable to the four-factor model of the original version. In this study, the exploratory factor analysis (EFA) result was not calculated since the fifteen items of the original questionnaire already indicated four factors as the best-structured model. The authors concluded that it would be more relevant to conduct a PCA to ascertain whether a new factor dimension model should be used [9]. Although the possibility of using a new model was presented, it turned out not to be as adequate as the four-factor dimension model. The achieved results in the analytical tests allowed us to choose a four-factor dimension model as the best-structured model for adapting and validating the Spanish and Catalan versions of the PBIAS. So far, the PBIAS scale has only been validated in Dutch and English [9] and in Spanish and Catalan. This may be due to the short time since the scale was first validated. It is likely that in time, as has happened with other scales [27–30], there will be further translations, adaptations, and validations of this scale into other languages and cultures, which will allow further studies to be carried out and it will become clearer whether the best model continues to be the four-factor model or whether there are other studies that also find the three-factor model to be valid. Thanks to this study, the Spanish version of the PBIAS is now available. This not only guarantees the existence of a positive body image assessment instrument for adolescents in Spanish-speaking countries (i.e., Spain and Latin America), but, together with the English version, the PBIAS can be used in countries where both languages coexist in parallel, such as in the United States. The validation of this scale in Spanish and Catalan increases the number of tools [31] in these languages that educators and health professionals can use in the prevention, detection, and assessment of mental health disorders in adolescents related to body image. More specifically, the PBIAS in Spanish and Catalan will make it possible to work on an important aspect such as the perception that many adolescents have of their own bodies and that of their peers. Through this scale, educators and health professionals will also be able to create working materials that are adapted to the needs of this type of adolescent and address mental health problems in a more specific and targeted way in high schools [32]. The validation of this tool in these two languages not only contributes to the achieve- ment of the project’s objectives but also to target 3.4 of the Sustainable Development Goal 3 (ensure healthy lives and promote well-being for all at all ages) [33]. Int. J. Environ. Res. Public Health 2023, 20, 4017 9 of 11 Limitations This study has identified three main types of constraints. The first is that we did not use a random sample, but a convenience sample. Another limitation is the heterogeneity of the participants in terms of gender (56.8% females versus 39.6% males) and age groups (26.4% were 12 to 14 years old, 72.1% were 15 to 17 years old, and 1.8% were older than 17 years old). This could lead to a potential selection bias affecting the obtained results. Finally, it was considered a limitation that the participants were not asked if they were taking any psychotropic drugs or if they were suffering from any mental disturbances at the time of the study that might influence their responses in the questionnaires. Future studies are needed to confirm the results presented here and to determine the influence of these limitations and possible biases introduced in this study. 5. Conclusions The Spanish and Catalan versions of the PBIAS instrument showed high levels of reliability and statistical validity comparable with the original version in English, and, therefore, it is a suitable instrument for assessing positive body image among adolescents in the Spanish and Catalan context. Educators and health professionals can implement this scale in their work with adolescents to detect potential mental health problems. This work provides a tool that contributes to the achievement of Goal 3 of the Sustainable Development Goals. Author Contributions: Conceptualization, G.T.-N., J.V.-A. and E.A.-B.; methodology, A.E., J.R. and J.V.-A.; software, A.E.; validation and formal analysis, A.E. and J.R.; resources, M.P.-P.; data curation, M.P.-P. and J.R.; writing—original draft preparation, G.T.-N., A.E. and E.A.-B.; writing—review and editing G.T.-N. and A.E., supervision, G.T.-N. and J.V.-A. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: The study was approved by the University Institute for Research in Primary Care (IDIAP) Jordi Gol i Gurina ethics committee (Code 21/295-P). Informed consent was obtained from all subjects involved in the study or through their mother, father, or legal guardian if the participant was under 15 years of age. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Data Availability Statement: Please contact the corresponding author (anna.espart@udl.cat) to request data. Acknowledgments: The authors would like to thank the translators and experts who helped them throughout the study, with special thanks to the directors and students from the high schools of Capellades (IES Molí de la Vila), Calaf (IES Alexandre de Riquer), and Lleida (Col.legi Episcopal) (Catalunya, Spain) who participated in it. Additionally, the authors would like to thank Maes for her generosity in letting us use the PBIAS scale. Conflicts of Interest: The authors declare no conflict of interest. References 1. Cash, T.F.; Smolak, L. Body Image: A Handbook of Science, Practice, and Prevention, 2nd ed.; The Guilford Press: New York, NY, USA, 2011. 2. Tort-Nasarre, G.; Pollina Pocallet, M.; Artigues-Barberà, E. The meaning and factors that influence the concept of body image: Systematic review and meta-ethnography from the perspectives of adolescents. Int. J. Environ. Res. Public Health 2021, 18, 1140. [CrossRef] [PubMed] 3. Bornioli, A.; Lewis-Smith, H.; Smith, A.; Slater, A.; Bray, I. Adolescent body dissatisfaction and disordered eating: Predictors of later risky health behaviours. Soc. Sci. Med. 2019, 238, 112458. [CrossRef] [PubMed] 4. Neumark-Sztainer, D.; Paxton, S.J.; Hannan, P.J.; Haines, J.; Story, M. Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males. J. Adolesc. Health 2006, 39, 244–251. [CrossRef] [PubMed] Int. J. Environ. Res. Public Health 2023, 20, 4017 10 of 11 5. Pollina-Pocallet, M.; Artigues-Barberà, E.; Tort-Nasarre, G.; Sol, J.; Azlor, L.; Foguet-Boreu, Q.; Ortega-Bravo, M. Self-perception and self-acceptance are related to unhealthy weight control behaviors in catalan adolescents: A cross-sectional study. Int. J. Environ. Res. Public Health 2021, 18, 4976. [CrossRef] [PubMed] 6. Stice, E. Risk and maintenance factors for eating pathology: A meta-analytic review. Psychol. Bull. 2002, 128, 825–848. [CrossRef] [PubMed] 7. Andrew, R.; Tiggemann, M.; Clark, L. The protective role of body appreciation against media-induced body dissatisfaction. Body Image 2015, 15, 98–104. [CrossRef] 8. Tylka, T.L.; Piran, N. Handbook of Positive Body Image and Embodiment: Constructs, Protective Factors, and Interventions; Oxford University Press: Oxford, UK, 2019. 9. Maes, C.; Trekels, J.; Tylka, T.L.; Vandenbosch, L. The Positive Body Image among Adolescents Scale (PBIAS): Conceptualization, development, and psychometric evaluation among adolescents from Belgium. Body Image 2021, 38, 270–288. [CrossRef] 10. Linardon, J.; Greenwood, C.J.; Fuller-Tyszkiewicz, M.; Macdonald, J.A.; Spry, E.; Hutchinson, D.M.; Youssef, G.J.; Sanson, A.; Wertheim, E.H.; McIntosh, J.E.; et al. Young adult mental health sequelae of eating and body image disturbances in adolescence. Int. J. Eat. Disord. 2021, 54, 1680–1688. [CrossRef] 11. Jáuregui-Lobera, I.; Iglesias Conde, A.; Sánchez Rodríguez, J.; Arispon Cid, J.; Andrades Ramírez, C.; Herrero Martín, G.; Bolaños-Ríos, P. Self-perception of weight and physical fitness, body image perception, control weight behaviors and eating behaviors in adolescents. Nutr. Hosp. 2018, 35, 1115–1123. [CrossRef] 12. Jiménez Flores, P.; Jiménez Cruz, A.; Bacardi Gascón, M. Insatisfacción con la imagen corporal en niños y adolescentes: Revisión sistemática [Body-image dissatisfaction in children and adolescents: A systematic review]. Nutr. Hosp. 2017, 34, 479–489. [CrossRef] 13. Tylka, T.L. Overview of the field of positive body image. In Body Positive: Understanding and Improving Body Image in Science and Practice; Daniels, E.A., Gillen, M.M., Markey, C.H., Eds.; Cambridge University Press: Oxford, UK, 2018; pp. 6–33. 14. Tylka, T.L.; Wood-Barcalow, N.L. What is and what is not positive body image? Conceptual foundations and construct definition. Body Image 2015, 14, 118–129. [CrossRef] [PubMed] 15. Halliwell, E. Future directions for positive body image research. Body Image 2015, 14, 177–189. [CrossRef] [PubMed] 16. Mansfield, R.; Humphrey, N.; Patalay, P. Educators’ perceived mental health literacy and capacity to support students’ mental health: Associations with school-level characteristics and provision in England. Health Promot. Int. 2021, 36, 1621–1632. [CrossRef] [PubMed] 17. Anttila, M.; Ylitalo, M.; Kurki, M.H.; Hipp, K.; Välimäki, M. School nurses’ perceptions, learning needs and developmental suggestions for mental health promotion: Focus group interviews. Int. J. Environ. Res. Public Health 2020, 17, 9503. [CrossRef] 18. Bjørnsen, H.N.; Espnes, G.A.; Eilertsen, M.B.; Ringdal, R.; Moksnes, U.K. The relationship between positive mental health literacy and mental well-being among adolescents: Implications for school health services. J. Sch. Nurs. 2019, 35, 107–116. [CrossRef] 19. Daubenmier, J.J. The relationship of yoga, body awareness, and body responsiveness to self-objectification and disordered eating. Psychol. Women Q. 2005, 29, 207–219. [CrossRef] 20. Cook-Cottone, C.; Guyker, W. The development and validation of the mindful self-care scale (MSCS): An assessment of practices that support positive embodiment. Mindfulness 2018, 9, 161–175. [CrossRef] 21. Tylka, T.L.; Wood-Barcalow, N.L. The body appreciation scale-2: Item refinement and psychometric evaluation. Body Image 2015, 12, 53–67. [CrossRef] 22. Cash, T.F.; Santos, M.T.; Williams, E.F. Coping with body-image threats and challenges: Validation of the Body Image Coping Strategies Inventory. J. Psychosom. Res. 2005, 58, 190–199. [CrossRef] 23. Sousa, V.D.; Rojjanasrirat, W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: A clear and user-friendly guideline. J. Eval. Clin. Pract. 2011, 17, 268–274. [CrossRef] 24. WHO. Process of Translation and Adaptation of Instruments. 2016. Available online: http://www.who.int/substance_abuse/ research_tools/Translation/en/ (accessed on 15 September 2022). 25. Argimon-Pallàs, J.M.; Flores-Mateo, G.; Jiménez-Villa, J.; Pujol-Ribera, E.; Foz, G.; Bundó-Vidiella, M.; Juncosa, S.; Fuentes-Bellido, C.M.; Pérez-Rodríguez, B.; Margalef-Pallarès, F.; et al. Study protocol of psychometric properties of the Spanish translation of a competence test in evidence based practice: The Fresno test. BMC Health Serv. Res. 2009, 9, 37. [CrossRef] [PubMed] 26. Vidal-Alaball, J.; Flores Mateo, G.; Garcia Domingo, J.L.; Marín Gomez, X.; Sauch Valmaña, G.; Ruiz-Comellas, A.; López Seguí, F.; García Cuyàs, F. Validation of a short questionnaire to assess healthcare professionals’ perceptions of asynchronous telemedicine services: The catalan version of the health optimum telemedicine acceptance questionnaire. Int. J. Environ. Res. Public Health 2020, 17, 2202. [CrossRef] [PubMed] 27. Cooper, P.J.; Taylor, M.J.; Cooper, Z.; Fairbum, C.G. The development and validation of the body shape questionnaire. Int. J. Eat. Disord. 1987, 6, 485–494. [CrossRef] 28. Hopwood, P.; Fletcher, I.; Lee, A.; Al Ghazal, S. A body image scale for use with cancer patients. Eur. J. Cancer 2001, 37, 189–197. [CrossRef] 29. Lawrence, J.W.; Heinberg, L.J.; Roca, R.; Munster, A.; Spence, R.; Fauerbach, J.A. Development and validation of the satisfaction with appearance scale: Assessing body image among burn-injured patients. Psychol. Assess. 1998, 10, 64–70. [CrossRef] 30. Avalos, L.; Tylka, T.L.; Wood-Barcalow, N. The body appreciation scale: Development and psychometric evaluation. Body Image 2005, 2, 285–297. [CrossRef] Int. J. Environ. Res. Public Health 2023, 20, 4017 11 of 11 31. Sánchez-Miguel, P.A.; Vaquero-Solís, M.; Sánchez-Oliva, D.; Pulido-González, J.J.; Segura-García, C.; Tapia-Serrano, M.A. Validation of the body image dimensional assessment in adolescents from Spanish high school. Eat. Weight Disord. 2021, 26, 1749–1756. [CrossRef] 32. Smith-Fromm, T.; Evans-Agnew, R.A. Educator preparedness for mental health in adolescents: Opportunities for school nurse leadership. NASN Sch. Nurse 2017, 32, 372–377. [CrossRef] 33. United Nations. Sustainable Development Goals. 2022. Available online: https://www.un.org/sustainabledevelopment/ (accessed on 10 October 2022). Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.