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Psychometric properties of the Chinese version of the body image life disengagement questionnaire in a sample of adolescents

BMC Psychology volume 13, Article number: 79 (2025) Cite this article

Abstract

Background

The negative consequences of body image concerns manifest in ways such as negative emotional experiences, eating disorders, and problems with social life. The Body Image Life Disengagement Questionnaire (BILD-Q) is an instrument for assessing the impact of body image concerns specifically on adolescents’ life disengagement. The objective of this study is to create a Chinese version of the BILD-Q and assess its validity and reliability with Chinese adolescents.

Methods

A total of 593 adolescents were recruited, of whom 316 (Sample 1) completed only the BILD-Q and 277 (Sample 2) completed the BILD-Q, Eating Attitudes Test (EAT), and Body Appreciation Scale-2 (BAS-2). Data from Sample 1 were used for the item analysis, exploratory factor analysis (EFA), and test-retest reliability, while data from Sample 2 were used for the BILD-Q’s confirmatory factor analysis (CFA) and associations of BILD-Q with EAT and BAS-2. Both samples were used together for calculating descriptive statistics, measurement invariance, and internal consistency. EFA and CFA were used to verify the single-factor structure of the BILD-Q. Measurement invariance across genders was verified by multi-group CFA. The reliability of the instrument was verified using Cronbach’s alpha and the intraclass correlation coefficient (ICC). Finally, the convergent validity of the instrument was verified by correlating the BILD-Q scores with the EAT and BAS-2 scores.

Results

The results support a single-factor structure for the Chinese version of the BILD-Q, with good reliability (Cronbach’s alpha = 0.888, ICC value = 0.759). Gender invariance was established: no significant differences were found in BILD-Q scores between the male and female groups. Life disengagement was positively correlated with eating disorder psychopathology and negatively correlated with body appreciation, supporting the convergent validity of the BILD-Q.

Conclusion

The Chinese version of the BILD-Q has strong psychometric properties when used with Chinese adolescents and can be used to assess the impact of body image concerns on their life disengagement.

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Introduction

Body image is a multidimensional construct that encompasses an individual’s subjective perception of their body, emotional experiences, and corresponding behavioral regulation [1, 2]. It is a well-known risk and maintenance factor for poor mental health and psychopathology, including eating disorders [3], and can be divided into independent constructs of positive body image and negative body image [4, 5]. The characteristics of positive body image are grouped into three categories of core characteristics (e.g., body appreciation, body acceptance/love, conceptualizing beauty broadly, inner positivity, interpreting information in a body-protective manner, and adaptive investment in appearance), characteristics that promote or maintain positive body image (e.g., media literacy), and utility characteristics (e.g., self-confidence and pro-social behavior) [4, 6]. Negative body image is conceptualized as poor body esteem, body dissatisfaction, or body shame and greatly affects the lives of many young people because it is associated with low overall well-being, low self-esteem, depression, and eating disorders [7]. It is worth noting that body image is a global mental health concern that is studied across many disciplines beyond medicine, psychology, and sociology [8]. For example, feminist researchers have found that feminist identity and beliefs have a protective effect against body image disturbance and the development of eating disorders [9]. This is because feminists’ views on social inequality and related issues make them more likely to recognize the thin ideal and Western beauty standards as tools used to oppress women [10]. In summary, body image is a complex topic that cuts across multiple disciplines and therefore must be studied from multiple perspectives.

Adolescence is an age when individuals experience dramatic changes in physical appearance, and is thus a very important period for the development of body image [7]. With the advent of the information age and widespread use of the Internet and social media, adolescents are increasingly subject to significant sociocultural influences that negatively impact their body image [11, 12, 13]. The tripartite influence model proposed by Thompson identifies three socio-cultural factors, namely parents, peers, and media, that are sources of influence on body image [14]. Studies to date have identified significant others (e.g., romantic partners, teachers, and coaches) as an additional socio-cultural factor [15]. Specifically, negative conversations about appearance between parents and children, including teasing the children about their weight, negative comments about their appearance, etc., lead to adolescents becoming dissatisfied with their weight and appearance and eventually developing a negative body image [16, 17]. Moreover, peers are the main social objects of adolescents, and thus peer teasing is a form of negative evaluation that deeply and negatively affects the development of their body image [18]. The more they are teased by their peers about their weight or appearance, the greater their dissatisfaction with their bodies will be, and the stronger the formation and consolidation of their negative body image will become [19]. Longitudinal evidence indicates that weight teasing in adolescence is strongly associated with eating disorders, negative body image, and obesity in adulthood [20, 21]. Social media have become an important platform for adolescents’ social interaction and thus an important channel for the dissemination of a body image ideal [22]. Evidence suggests that frequent and prolonged use of social media by adolescents has a negative impact on their body image, leading to increasing body dissatisfaction [23]. Roberts found that social media was the only source of pressure associated with appearance esteem for adolescent girls in the United States, through both internalization of the thin ideal and body comparison [22]. Available evidence also suggests that appearance-related stress from significant others is associated with adolescents’ body mass index, body esteem, and eating disorders [3, 24]. In conclusion, sociocultural factors, in particular modern communications media such as social media, have a significant impact on adolescents’ body image concerns, substantially contributing to the occurrence and development of negative body image.

In China, body image concerns are a prominent issue among adolescents. In a survey of 10,070 adolescents in Shanghai, China, 43.45% of adolescents were found to be dissatisfied with their weight and 30.46% had experienced weight teasing [18]. Body image concerns have a wide range of negative consequences: adolescents’ perceived weight stigma, weight dissatisfaction, and body dissatisfaction are associated with depression [25], eating disorders [26], low self-esteem [27], and even suicidal ideation [28]. In addition to these negative impacts on mental health, there is also evidence that body image concerns have a negative impact on life engagement. Adolescents in the school setting may engage in maladaptive coping strategies such as skipping classes or even skipping school as a result of feelings of dissatisfaction or shame about their appearance [29] and may also avoid physical sports and social activities [30, 31, 32]. Although such maladaptive behaviors may provide an immediate sense of relief from the negative psychological issues associated with body image concerns, they can also reinforce these concerns and ultimately limit their exposure to life experiences that would be conducive to their individual growth and psychological well-being [33]. A growing body of research focuses on the broader consequences of body image concerns, but there is still a lack of validated instruments for assessing the impact of such concerns on Chinese adolescents’ engagement in their education, social intercourse, sports participation, and other domains of life. To the best of our knowledge, the one validated and brief measure that can be used in for this purpose is the Body Image Life Disengagement Questionnaire (BILD-Q) [34].

The initial items of the BILD-Q were based on a market research instrument developed for the Dove Self-Esteem Project that is used globally to assess body image in women and girls and the impact of body image concerns on their life activities [34]. Specifically, the content of the items is based on the results of a qualitative analysis of data from focus group discussions and interviews with women aged 20–55 years (126 in total) and girls aged 11–13 years (36 in total), conducted in the UK, Brazil, France, Indonesia, Japan, and China. Following the modification of these items to ensure their applicability to adolescents, they were subjected to psychometric testing by Atkinson and Diedrichs [34]. The resulting BILD-Q questionnaire consists of nine items assessing adolescents’ perceptions of the impact of their body image concerns on different life domains, such as the extent to which worry or discontent about their appearance prevents them from going to school, going shopping for clothes, attending social events, and other activities. The items are scored on a 4-point Likert scale from 1 = hasn’t stopped me at all to 4 = stopped me all the time. The BILD-Q was initially validated for British adolescents and exhibited good convergent validity, concurrent validity, incremental validity, gender invariance, test-retest reliability, and internal consistency. The single-factor structure of the BILD-Q has been replicated in a sample of adolescents in urban India, and the gender invariance in that context has also been verified.

Although the available evidence suggests that the BILD-Q has adequate psychometric properties, to the best of the authors’ knowledge, there is no validated version of the BILD-Q specifically for use with Chinese adolescents. The objective of this study is thus create a Chinese version of the BILD-Q for Chinese adolescents and assess its validity and reliability. Based on the existing literature, we hypothesized that body image life disengagement is negatively associated with positive body image and positively associated with eating disorder psychopathology. In addition, we hypothesized that the Chinese version of the BILD-Q would have a single-factor structure like that of the original scale, and that it would be invariant across genders.

Methods

Participants and procedure

This study used two samples: Sample 1 was used to examine the BILD-Q’s item analysis, exploratory factor analysis (EFA), and test-retest reliability, while Sample 2 was used to examine the BILD-Q’s Confirmatory Factor Analysis (CFA) and associations with eating attitude and body appreciation. The two samples were used together to examine the BILD-Q’s descriptive statistics, measurement invariance, and internal consistency. The two samples were collected independently between October and November 2024. EFA and CFA have different requirements for adequate sample sizes: for EFA, the sample size should ensure a 10:1 participant-to-item ratio, or more strictly 20:1 [35], while for CFA, the sample size should be greater than 100 and the participant-to-item ratio should be at least 5:1 [36]. Therefore, a minimum valid sample size of 190 was required for this study. After excluding invalid data (e.g., incomplete answers or excessive selection of the same option), there were 316 valid participants for Sample 1 and 277 valid participants for Sample 2, for a total of 593 participants. The study population was Chinese adolescents.

Inclusion criteria: (1) age 10–19 years [37]; (2) basic literacy in the Chinese language; and (3) voluntary participation.

Exclusion criteria: (1) a history of mental disorders or currently diagnosed with a mental disorder (including but not limited to schizophrenia, bipolar disorder, etc.)

The data were collected offline using paper-based questionnaires. Participants were from a public school in Guangdong, China. Prior to inviting them to participate in this study, consent was obtained from the school headmaster. For adolescents under 18 years, informed consent was obtained from the adolescent and at least one parent prior to participation. For adolescents 18 years and older, informed consent was only obtained from the adolescents themselves. Participants were assured of the right to withdraw from the study at any time. Anonymity of the adolescents’ participation and responses was guaranteed. Data collection was approved by the Medical Ethics Committee of The First Affiliated Hospital of Fujian Medical University (Project number: (2024QT) No. (224)).

Instruments

Body Image Life Disengagement Questionnaire (BILD-Q)

This instrument was developed by Atkinson and Diedrichs [34]. It comprises nine items, devised to assess the impact of body image concerns on life engagement. As mentioned above, all items are scored on a 4-point Likert scale from 1 = hasn’t stopped me at all to 4 = stopped me all the time. The overall score is calculated as an average of the scores for all nine items, with higher scores indicating higher life disengagement. The Chinese version of the BILD-Q was translated and culturally adapted before it was used in this study. With the permission of the original author, we followed the guidelines recommended in the field of body image for translation [36]. First, the instrument was independently translated into Chinese by an informed master’s student and an uninformed bilingual translator, both of whom are native speakers of Chinese. Second, the first author and these two translators discussed and reviewed the differences between the two independent translations and the original text, resulting in a synthesized translation. Third, an uninformed PhD in medicine and a native English translator independently back-translated the synthesized translation back into English. Fourth, in addition to the research team, two psychologists compared and reviewed the original version and the back-translation to identify and correct any discrepancies and ensure the accuracy of the translation. Finally, pre-tests and cognitive interviews were conducted with 20 adolescents (10 girls, 10 boys) prior to the start of formal data collection to ensure that all questions were easily understandable to participants. The results showed that the adolescents understood all the items well, except item 5. We added explanations to this item. After this was completed, no further problems were found with any of the items. Five psychologists assessed the content validity of the Chinese version of the BILD-Q; the item-level content validity index was 0.8 to 1.0, while the scale-level content validity index was 0.93.

Eating Attitudes Test (EAT)

The EAT, used to assess the risk of eating disorders, was developed by Garner and Garfinkel and the original version comprised 40 items [38]. This was later simplified by Garner to a 26-item version [39]. Examples of items include “I vomit after I have eaten” and “I am preoccupied with the thought of having fat on my body”. All items are scored a 6-point Likert scale ranging from 1 = never to 6 = always. The higher the score, the more likely the individual’s eating attitudes and behaviors are to deviate from normal and the greater their likelihood of developing an eating disorder. This study used the Chinese version of the EAT as developed by Wang, which comprises 19 items [40]. Six items were deleted from the Chinese version; five of these were deleted because they did not pass the project analysis, and the remaining one was deleted because the item communality did not meet the standards. The Chinese version of the EAT contains four factors, namely dieting, bulimia and food preoccupation, perception of food content, and compensatory behavior. It has good reliability and validity. In this study, the Cronbach’s alpha coefficient of this scale was 0.875.

Body Appreciation Scale-2 (BAS-2)

The BAS-2 was developed by Tylka and Wood-Barcalow and comprises 10 items [41]. This scale is used to assess individuals’ acceptance of, favorable opinions toward, and respect for their bodies. Sample items include, “I respect my body” and “My behavior reveals my positive attitude toward my body; for example, I hold my head high and smile”. All items are scored on a 5-point Likert scale ranging from 1 = never to 5 = always, with higher scores indicating higher levels of self-body appreciation. The Chinese version of the BAS-2, translated and validated by Swami, was used in this study. It has good reliability and validity [42]. In this study, the Cronbach’s alpha coefficient of this scale was 0.943.

Data analysis

IBM SPSS Statistics 26.0 and AMOS 24.0 were used for data analysis. Demographic characteristics were summarized using descriptive statistics.

Item analysis

The correlation coefficient method and the critical ratio method were used as follows: (1) Correlation coefficient method: The correlation between each item of the scale and the total score was calculated (i.e., the item-total correlation (ITC)). A correlation coefficient > 0.40 is deemed excellent, while a coefficient of 0.3 ~ 0.4 is considered good. Correlation coefficients < 0.3 generally need to be removed. (2) Cronbach’s alpha coefficient method: This method compares the change in the Cronbach’s alpha coefficient of the scale before and after an item is removed (i.e., Alpha if Item Deleted (AID)). If there is a significant increase in the Cronbach’s alpha coefficient of the scale after an item is deleted, then the item should be deleted.

Factor analysis

Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to explore the factor structure of the Chinese version of the BILD-Q. Sample 1 (316 individuals) was used for EFA and Sample 2 (277 individuals) was used for CFA. EFA was analyzed by principal axis factoring and oblique (promax) rotation. The suitability of the target instrument for factor analysis was evaluated based on Kaiser-Mayer-Olkin (KMO) values (≥ 0.7) and Bartlett’s test of sphericity (p < 0.05) [43]. Factors with eigenvalues greater than 1 were retained [44]. Parallel analysis was used to further identify the factors to be retained [45]. Items with factor loadings less than 0.5 were removed. The fit of the factor structure obtained from the EFA was determined by means of CFA. The following indices were used to assess the goodness of fit of the data: the chi-square-to-degrees-of-freedom ratio (χ2/df), the comparative fit index (CFI), the Tucker-Lewis index (TLI), the Root Mean Square Error of Approximation (RMSEA), and the Standardized Root Mean Square Residual (SRMR). The criteria of χ2/df < 5, CFI and TLI ≥ 0.90, RMSEA ≤ 0.10, and SRMR ≤ 0.10 indicate an acceptable fit [46, 47]. We mainly referred here to the SRMR, which has been found to be robust to different estimators [48, 49].

Convergent validity

Pearson’s correlation coefficient was used to assess the convergent validity of the BILD-Q. Absolute correlation coefficients (r) values < 0.3, 0.3 < values < 0.5, and values > 0.5 are considered weak, moderate, and strong correlations, respectively [50].

Reliability

Cronbach’s alpha value and test-retest reliability were used to evaluate the BILD-Q’s reliability. Cronbach’s alpha was used to determine the extent of acceptable internal consistency, which is generally considered acceptable when > 0.7 [51]. Test–retest reliability was assessed using the intraclass correlation coefficient (ICC) and a 95% confidence interval (CI). ICC values > 0.75 are considered “excellent”, those 0.60–0.74 are “good”, 0.40–0.59 are “moderate”, and < 0.40 are “poor” [52].

Gender invariance

To examine the gender invariance of BILD-Q scores, we conducted multi-group CFA using the total sample [53]. Measurement invariance was assessed at the configural, metric, and scalar levels [54, 55]. The criteria of ΔCFI < 0.010 and ΔRMSEA < 0.015 or ΔSRMR < 0.030 (for metric invariance) and < 0.010 (for scalar invariance) were used as evidence of measurement invariance [56].

Normal distribution and outliers

Univariate normal distribution was tested using skewness and kurtosis tests and the Shapiro-Wilk test. Univariate outliers were tested using Boxplot. Multivariate outliers were tested using the Mahalanobis distance.

Results

Participants

A total of 593 participants were enrolled in the study. Their mean age was 15.80 ± 0.62 years (age range 14–18 years). All participants were Han Chinese, of whom 77.2% were female.

Item analysis

The results of the item analysis showed that none of the items needed to be deleted (see Table 1).

Table 1 Item analysis results of the Chinese BILD-Q (n = 316)
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Factor analysis

Exploratory factor analysis

The results showed that the KMO value was 0.92 and the Bartlett’s sphericity test value was 1857.59 (p < 0.001), indicating that the data were suitable for factor analysis. One factor with an eigenvalue greater than 1 was extracted using principal axis factoring and oblique (promax) rotation. The results of the parallel analysis similarly showed that only one factor needed to be retained. The variance interpretation rate of this factor was 63.18%. This factor comprises nine items, each with a factor loading greater than 0.5 (see Table 2).

Table 2 Results of the final EFA of the BILD-Q (n = 316)
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Confirmatory factor analysis

CFA showed that the one-factor model of BILD-Q had insufficient goodness of fit: χ2/df = 8.026 (p < 0.001), CFI = 0.801, TLI = 0.735, RMSEA = 0.16, SRMR = 0.085. Following modification of the model in accordance with the modification indices (MI) (MI values: items 2–3 (48.204), items 5–8 (39.284), items 7–8 (23.355), items 2–6 (10.574), items 7–9 (8.979)), an improvement in model fit was observed (Table 3), with the χ2/df, CFI, RMSEA, and SRMR all within acceptable limits (χ2/df = 2.533 (p < 0.001), CFI = 0.965, TLI = 0.942, RMSEA = 0.075, SRMR = 0.0495). The modified one-factor model is thus considered acceptable [53] (see Fig. 1).

Table 3 Comparison of initial and modified models by CFA
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Fig. 1
figure 1

Results of CFA for the Chinese version of the BILD-Q

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Convergent validity

The BILD-Q exhibited a moderately positive correlation with the EAT (r = 0.463, p < 0.01) and a moderately negative correlation with the BAS-2 (r = -0.438, p < 0.01).

Reliability

Based on analysis of Sample 1 and Sample 2, the Cronbach’s alpha coefficient of the Chinese version of the BILD-Q was 0.888. Thirty adolescents from Sample 1 took the test again two weeks later, yielding an ICC value of 0.759. These results indicate that the Chinese version of the BILD-Q has good validity and stability over time.

Gender invariance

The results demonstrated that the Chinese version of the BILD-Q exhibits gender invariance at the configural, metric, and scalar levels (see Table 4). No significant difference was seen between females and males in terms of BILD-Q scores (females-males (mean (SD)): 1.38 (0.49)-1.32 (0.46); t (591) = 1.29, p = 0.196).

Table 4 Tests of measurement invariance of the Chinese version of the BILD-Q (n = 593)
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Discussion

In this study, the nine-item BILD-Q [34] was translated into Chinese and validated with Chinese adolescents. To the best of our knowledge, this study is the first to translate the BILD-Q into a Chinese version and test its reliability and validity, providing a practical and reliable instrument for further exploration of the field in China. Specifically, we examined the psychometric properties of the Chinese version of the BILD-Q in terms of factor structure, internal consistency reliability, cross-gender measurement invariance, and convergent validity.

Item analysis showed that the Chinese version of BILD-Q has good discriminatory power, with ITC values above 0.4 for all items, meeting the acceptance criteria. Thus, no items were deleted in this step. EFA showed that one factor could be extracted from all items according to the Guttman-Kaiser criteria [57, 58]. The factor loadings on all items of this instrument were above 0.6, with an explanation rate of more than 60%, indicating that the BILD-Q is a good measure of the extent to which adolescents’ life activities are affected by their body image concerns. The one-factor structure of the Chinese version of the BILD-Q is similar to that of the original and Indian versions [33, 34]. The factor structure was not examined separately by gender in this study because the male sample was too small to permit such an analysis.

The unidimensional structure of the Chinese version of the BILD-Q was further validated in CFA, confirming its cross-cultural stability. This was expected, as the content of the BILD-Q’s items was initially developed based on qualitative insights from focus group discussions and interviews with women aged 20–55 years and girls aged 11–13 years in the UK, Brazil, France, Indonesia, Japan, and China [34]. This cross-cultural perspective helps to ensure that the questionnaire covers specific issues and concerns that are present across different cultures. In addition, we freed the error covariance between the five pairs of items to improve model fit. This procedure is often related to method effects introduced during the cultural adaptation process, as multiple items may imply similar meanings to each other once they are translated into Chinese [59, 60]. For example, Chinese adolescents may perceive some similarities in wording or intent between items 2 “Participate in social events, such as friends or class parties” and 3 “Go shopping for clothes”, and between items 5 “Give an opinion or stand up for myself” and 8 “Raise my hand in class”. For Chinese adolescents, socializing may involve going shopping, and expression of opinions by adolescents usually occurs in the classroom, where they are typically required to raise their hands to answer questions. Item 5 may also encompass many other situations, such as making decisions about entertainment when playing with friends. As far as the Chinese version is concerned, item 5 is similar to item 8, but may not be as clear as item 8, and is in fact broader in scope than item 8. The other three pairs of items were interpreted similarly.

The mean values for the Chinese version of the items showed that items 1 (“Go to the pool or beach”) and 5 (“Give an opinion or stand up for myself”) were associated with higher levels of life disengagement, while item 9 (“Spend time with friends and family”) was associated with lower levels of life disengagement. The activities associated with higher levels of life disengagement may be related to feeling body-related embarrassment in public places, as Western research has demonstrated that adolescents can feel embarrassed by body exposure in swimming pools or on the beach [61]. However, there is a lack of research on Chinese adolescents’ experiences of body-related embarrassment during sports or activities, and this question should be explored in depth in the future. A slight difference between these findings and those found among Indian adolescents was that the mean score on item 5 was slightly higher than that on item 1. The Indian adolescent group was least likely to engage in activities such as going to the beach or swimming pool due to appearance concerns, followed by expressing an opinion, while the Chinese adolescents reported the opposite. It is reasonable to hypothesize that this may be due to the sample in this study being from the coast, whereas adolescents from inland may be more likely to refuse to go to the beach or swimming pool due to appearance concerns. Since the item 5 mean score was only 0.01 higher than item 1 among Chinese adolescents, this explanation needs to be further explored in the future among adolescents from inland regions of China and from other, non-Chinese cultures. Alternatively, the difference may be due to the different cultures of China and India. In India, girls already have lower participation rates in sports and similar activities compared to boys [62], largely attributed to the pervasive gender bias and the influence of deeply entrenched attitudes towards gender roles in Indian society [63, 64]. These factors may lead to a bias in the way Indian girls perceive the impact of physical appearance issues on their life activities. Meanwhile, the situation in China is different, in that the concept of gender equality has gradually taken root in the public consciousness there [65]. Despite the differences, it seems clear that these two activities may be the most vulnerable to body image concerns, at least in China and India at present. Turning to activities related to low-level disengagement, item 9 (“Spend time with friends and family”) had the lowest mean score, consistent with what has been found for Indian adolescents. This might indicate that the adolescents were least likely to be affected by appearance concerns when participating in this activity. Prior studies have found that adolescents are likely to feel more comfortable with family and friends, who may value them more for qualities other than their physical appearance and act as their supporters [33]. In summary, the findings for Chinese adolescents support the results of prior research and further raise new questions, and thus the above-mentioned hypotheses should be further explored in future cross-cultural studies on the BILD-Q.

The Chinese BILD-Q was positively correlated with the EAT and negatively correlated with the BAS-2, further supporting its convergent validity. The moderate association between the BILD-Q and eating disorders has been identified in previous studies and was reproduced in the present study [33, 34]. It is important to note that different studies used different instruments to assess eating disorders. The EAT [39] was used in this study, whereas the Clinical Impairment Assessment (CIA) [66] was used in the original version, and the Eating Disorder Examination Questionnaire (EDE-Q) [67] was used in the Indian version. The original BILD-Q showed a strong correlation with the CIA (r = 0.62, p < 0.01), and in the present study BILD-Q showed a moderate correlation with the EAT (r = 0.463, p < 0.01). Multiple eating disorder-related assessment instruments have shown significant associations with the BILD-Q, emphasizing the need to further explore the relationship between eating disorders and life disengagement. This study also found low levels of life disengagement to be associated with high levels of body appreciation. Prior studies have found a moderate to strong relationship between the BILD-Q and the Body Esteem Scale for Adults and Adolescents (BESAA) [68]. It is important to note that the BESAA was not specifically developed to assess positive body image, whereas the BAS-2 used in this study was.

In addition, this study established the gender invariance of the Chinese version of the BILD-Q, demonstrating the applicability of the instrument across genders and consistent with the results for the original and Indian versions of the BILD-Q. This means that the BILD-Q measures the same structures in the same way for girls and boys, allowing for a latent means of comparison across gender. As for comparisons between genders, our study showed no significant differences between genders in terms of BILD-Q scores. In the original version, girls scored significantly higher than boys; in the Indian version, boys scored significantly higher than girls [33, 34]. This may be related to the unbalanced gender ratio of the sample used in this study, and this should be further examined by increasing the sample size in the future.

Regarding the reliability of the Chinese version of the BILD-Q, the Cronbach’s alpha coefficient was 0.888 and the ICC value was 0.759. The Cronbach’s alpha of the Chinese version was thus close to that of the original and slightly higher than that of the Indian version. The Chinese version of the BILD-Q exhibited good test-retest reliability over a two-week period, suggesting that the instrument is relatively stable over time and less affected by chance. However, it is important to note that the sample used for the test-retest reliability analysis was small.

Implications and limitations

The findings of this study are useful for the study of adolescent body image in the following ways. This study is the first to test the reliability and validity of the BILD-Q from multiple perspectives in the Chinese cultural context, providing evidence of its cross-cultural applicability and increasing confidence in the further extension of the instrument to other countries. Second, researchers can use the Chinese version of the BILD-Q to conduct longitudinal studies tracking participants’ life disengagement across early, middle, and late adolescence to further understand the impact of body image issues on adolescents’ participation in the activities of daily living. Third, the results of this study provide useful information for future cross-cultural studies using this instrument. In particular, the issue of geographical location and cultural differences in the sample should be explored further.

This study has the following limitations that must be acknowledged, and that point to directions for future research. First, the data were collected through non-probability sampling methods, and this may have introduced selection bias and limited the generalizability of our findings. Second, the sample was taken from only one province in the southern region of China, and thus our findings are not necessarily applicable to adolescents from other cultural backgrounds. The average age of the sample was 15.8 years, and the sample consisted predominantly of girls and older adolescents. These may limit the applicability of the findings to a broader population. Moreover, the southern province studied here is relatively affluent. This may not reflect the experiences of adolescents in other areas, particularly in rural or less urbanized areas. Future studies should thus recruit participants from more regions of China, especially inland areas. Third, the use of a cross-sectional design limited the scope of the survey, and thus further testing of the predictive validity of the Chinese version of the BILD-Q is necessary. Fourth, our findings relied heavily on quantitative measures, which may overlook the nuances of the experiences and perspectives of adolescents regarding body image and life engagement. Fifth, for the purpose of reducing adolescents’ stress in completing the questionnaire, the present study omitted potentially confounding variables such as socioeconomic status, family dynamics, and peer influences on body image perceptions and life engagement. Future in-depth studies on the relationships between these variables and body image life disengagement would be valuable. And the credibility of the ICC value is limited because the sample involved in the retest is small. Finally, because of the gender imbalance of the sample in this study, the credibility of its gender invariance is limited. Future tests of measurement invariance across genders are needed using gender-balanced samples.

Conclusion

In conclusion, the findings of the present study confirm that the Chinese version of the BILD-Q has strong psychometric properties and can be used to assess the impact of body image concerns on Chinese adolescents’ life disengagement. The Chinese version of the BILD-Q is a brief and practical instrument consisting of nine items with a one-factor structure.

Data availability

The datasets used and analyzed in the current study are available from the corresponding author upon reasonable request.

Abbreviations

BILD-Q:

Body Image Life Disengagement Questionnaire

EAT:

Eating Attitudes Test

BAS-2:

Body Appreciation Scale-2

EFA:

Exploratory factor analysis

CFA:

Confirmatory factor analysis

ICC:

Intraclass correlation coefficient

ITC:

Item-total correlation

χ2/df:

Chi-square-to-degrees-of-freedom ratio

CFI:

Comparative fit index

TLI:

Tucker-Lewis index

RMSEA:

Root mean square error of approximation

SRMR:

Standardized root mean residual

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Acknowledgements

The authors would like to thank Dr. Melissa J. Atkinson for allowing the use of this instrument, as well as all of the adolescents who participated in this study.

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Author notes

  1. Kun Zhang and Huixing Huang contributed equally to this work.

Authors and Affiliations

  1. School of Nursing, Fujian Medical University, Fuzhou City, China

    Kun Zhang & Rongjin Lin

  2. The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou City, China

    Huixing Huang

  3. Department of nursing, School of Medicine, Zhongshan Hospital of Xiamen University, Xiamen University, Xiamen City, China

    Qiaosong Wang

  4. School of health management, Fujian Medical University, Fuzhou City, China

    Lin Ye

  5. The First Affiliated Hospital of Fujian Medical University, Fuzhou City, China

    Rongjin Lin

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Contributions

KZ conceptualized the study. KZ, HH, and LY analysed, interpreted the data and wrote the main manuscript. KZ and QW reviewed the related literature and wrote the manuscript. KZ and HH collected and curated the data. RL got project-administrated, supervised the study, and reviewed the manuscript critically. The authors have read and approved the final manuscript.

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Correspondence to Rongjin Lin.

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The study was approved by the Branch of Medical Research and Clinical Technology Application, Medical Ethics Committee, The First Affiliated Hospital of Fujian Medical University (Grant number: MTCA, ECFAH of FMU [2015]084 − 2; Valid from 2022-04-02 to 2025-04-01; Project number: (2024QT) No. (198)). All participants provided informed written consent after being informed about the aims of the research, and the study data were kept confidential. All procedures were followed in accordance with the Declaration of Helsinki.

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Zhang, K., Huang, H., Wang, Q. et al. Psychometric properties of the Chinese version of the body image life disengagement questionnaire in a sample of adolescents. BMC Psychol 13, 79 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40359-025-02411-x

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