The Body Appreciation Scale-2: Psychometric evaluation of the Puerto Rican Spanish version among women aged ≥ 50 years who are breast cancer survivors

Abstract

Purspose:

Self-perceived body image may impact women’s well-being and levels of depressive symptomatology after cancer-related treatment. The Body Appreciation Scale-2 (BAS-2) is a 10-item, unidimensional tool used to assess body appreciation, a facet of body image. A culturally relevant version of the BAS-2 was needed for the Spanish spoken in Puerto Rico. A cross-cultural adaptation of the BAS-2 for Spanish spoken in Puerto Rico was conducted and tested its psychometric properties, using a methodological design. It was hypothesized that the BAS-2 adapted for Puerto Rican Spanish would have an internal consistency with a Cronbach α value greater than 0.70 and a unidimensional structure; and that body appreciation would be positively and significantly correlated to mental health and would be negatively and significantly correlated to depression and body mass index.

Methods:

One hundred-nine participants were recruited with a diagnosis of breast cancer (stages 0 to III) who completed adjuvant curative therapy at least two months to five years prior to recruitment.

Results:

Participants had an average age of 61.5 years (SD = 7.1), and 64.2% had a bachelor’s degree or higher educational level. The internal consistency of the BAS-2 adapted for the Puerto Rican Spanish was Cronbach α = 0.92. Exploratory factor analysis indicated one-dimensionality of the test. Body appreciation was negatively correlated with higher levels of depressive symptomatology and with a higher body mass index, and positively correlated with higher levels of mental health.

Conclusion:

The BAS-2 adapted for the Spanish of Puerto Rico is a psychometrically sound instrument to assess body image.

Breast cancer treatment impacts body image,¹ which in turn has the potential to impact attitudes and behaviors regarding health.² Therefore, it is important to include the evaluation of body image as part of the health management of women who have undergone breast cancer treatments and reconstructive surgeries.³ For this evaluation, it is crucial to include reliable measures adapted to the cultural context of women with a history of breast cancer, which would allow a better understanding of the relationship between body image and health-related outcomes. One of the instruments used to assess a facet of body image, body appreciation, is the Body Appreciation Scale-2 (BAS-2).⁴

The BAS-2 specifically measures concepts of positive body image. This instrument is comprised of five major concepts: 1) an individual’s love and respect for their own body that allows them to appreciate its uniqueness and functionality; 2) acceptance of their body, including the aspects inconsistent with idealized images; 3) feeling happy with their body; 4) focusing on their body’s positives rather than perceived imperfections, and 5) processing information in a body-protective manner.⁵ The original BAS was revised to emphasize that deviations from societal beauty ideals do not represent imperfections, but unique characteristics that can be accepted and even appreciated.⁶ This revision led to the removal of eight items from the 13-item BAS and the addition of five new items to the BAS-2. Both the original BAS and the BAS-2 have undergone extensive cultural adaptations and validations.

Although there is a translation of the BAS-2 adapted for the Spanish spoken in Mexico, Argentina, and Colombia,7 the translation of items seven, eight, nine, and 10 did not maintain idiomatic equivalence and affected the interpretation of the items. Thus, it was necessary to use a version of the BAS-2 adapted for Puerto Rican Spanish. The present study aimed to 1) describe the cross-cultural adaptation process of the BAS-2 for the Puerto Rican Spanish; and 2) assess the internal consistency and construct validity, in a sample of women who are breast cancer survivors aged 50 years and older. It was hypothesized that the BAS-2 adapted for Puerto Rican Spanish would have an internal consistency with a Cronbach α value greater than 0.70; it would have a unidimensional structure; it would be positively and significantly related to mental health; and it would be negatively and significantly related to depression and body mass index.

Methods

Design

The psychometric properties of the Puerto Rican Spanish-translated version of the BAS-2 were examined using a methodological design.⁸

Participants

This study is part of an ongoing study assessing the effect of low- and moderate-intensity exercise programs on physical functioning among breast cancer survivors; and received ethical approval from the Institutional Review Board at the University of Puerto Rico, Medical Sciences Campus, under protocol number A0050116. The inclusion and exclusion criteria aligned with those of the parent ongoing study. Exclusion criteria aimed to safeguard women potentially at risk or susceptible to harm in the exercise programs outlined by the original study. Candidates who were already compliant with exercise guidelines were also excluded. Inclusion criteria required participants to be 50 years of age or older, as this is the median age for developing breast cancer in Puerto Rico,⁹ diagnosed with cancer between stages 0 and III, and to have completed adjuvant curative therapy at least two months to five years prior to recruitment. Women with contraindications to exercise, such as extreme tiredness, anemia, unstable heart disease, uncontrolled diabetes, uncontrolled high blood pressure, bleeding problems, inability to walk independently, stage IV breast cancer, another type of cancer, or who already met national exercise standards of greater than or equal to 150 min per week of moderate exercise, were excluded. Several recruitment strategies were used. These strategies included: 1) the use of the media such as newspaper ads, presentations in TV programs, and Facebook; and 2) personally addressing physicians and patients by visiting and presenting the project in medical offices, hospitals, cancer centers, and health fairs.

Measurements

The outcome measures assessed include body appreciation, depression, mental health, and BMI measured by the BAS-2,⁴ Beck Depression Index II (BDI-II),¹⁰ the Mental Health subscale of the Global Health Scale of the Patient-Reported Outcomes Measurement Information System (PROMIS),¹¹ and self-reported data of weight and height.

Body appreciation

The BAS-2 is a unidimensional test, consisting of 10 items that assess body acceptance and love, broad conceptualization of beauty, adaptive appearance investment, inner positivity, and tendency to filter information in a body-protective manner (Table 1). It uses a 5-point Likert scale ranging from 1 (Never) to 5 (Always). A score is obtained by an average of all items; a higher score indicates a higher body appreciation. The BAS-2 has been previously validated in Spanish-speaking populations. In Spanish adults, scores showed excellent internal consistency (Cronbach’s alpha of 0.90 to 0.94) for both genders.¹² Similarly, a study among adolescents from Argentina, Mexico, and Colombia demonstrated high internal consistency (Cronbach’s alpha of 0.93 to 0.94).⁷ The BAS-2 has shown measurement invariance across 65 nations, including nations in Central and South America.¹³ Incorporating the original authors’ authorization, this manuscript undertakes an extended exploration of scale development, building upon the foundations established by the initial work.

Table 1.

Concepts of positive body image reflected in the items of the BAS-2.

Theoretical concepts	Definition		Items that reflect the concept
Body acceptance and love	The expression of love and comfort with the body, even if not completely satisfied with all its aspects	2.	I feel good about my body.
		3.	I feel that my body has at least some good qualities.
		6.	I feel love for my body.
		9.	I am comfortable in my body.
Broadly conceptualizing beauty	The perception that a wide range of appearances can be beautiful	7.	I appreciate the different and unique characteristics of my body.
adaptive appearance investment	Engaging in appearance-related self-care that projects an individual's sense of style and personality	1.	I respect my body.
		5.	I am attentive to my body’s needs.
Inner positivity	The connection between positive body image, positive feelings, and adaptive behaviors.	4.	I take a positive attitude toward my body.
		8.	My behavior reveals my positive attitude toward my body; for example, I walk holding my head high and smiling.
Filtering information in a body-protective manner	Accepting information that is consistent with positive body image while rejecting messages that could endanger it.	10.	1 feel like I am beautiful even if I am different from media images of attractive people (e.g. models, actresses/actors).

Depression

The Beck Depression Inventory-II (BDI-II) is a self-report instrument for measuring symptoms, characteristics, and attitudes related to depression. It consists of 21 items with multiple self-reported responses between four and seven response options organized from least to greatest severity of a particular depression symptom. In those diagnosed with depression, scores of 0–13 indicate minimal depression, 14–19 indicate mild depression, 20–28 indicate moderate depression, and 29–63 indicate severe depression. This scale has excellent internal consistency (Cronbach α=.90); and convergent construct validity analysis indicates a strong correlation with the Epidemiologic Studies Depression Scale (r = 0.72) in a sample of patients with breast cancer.¹⁴ The Spanish version has been shown to have acceptable psychometric properties among hospitalized patients and a high discriminatory capacity between people with and without depression with a sensitivity of 87.5% and a specificity of 98.2%.¹⁵ A measure to determine levels of depression symptomatology was included, given the significant physical and psychological stress of breast cancer. It was expected to be an inverse correlation between depression and body appreciation.

Mental health

The Global Mental Health subscale of the PROMIS Item Bank v.1.0/1.1 Global Health was used to assess mental health. It contains four items to assess quality of life, mental health including mood and ability to think, satisfaction with social activities and relationships, and emotional problems such as anxiety, depression, or irritability. The Global Mental Health subscale has a Cronbach α=.86.¹¹ Its score can be transformed to a T-value and compared to the normal distribution of the general population. A score of 50 is the average for the general population of the United States (SD = 10). A higher score represents higher mental health.¹⁶

Body mass index (BMI)

BMI was included because its correlation with the BAS-2 was assessed in previous psychometric analyses.¹² Body mass index was calculated by using self-reported height and weight measurements with the following formula: weight (kg)/[height (m)]2.¹⁷ BMI scores were interpreted using standard weight status categories for adults.¹⁷

Sample size calculation

The recommended minimum of 100 participants,¹⁸ and a minimum of 10 participants per test item¹⁹ was used to determine sample size.

Procedure

The study was comprised of two phases. For the first phase, a multi-stage process was conducted to complete the cross-cultural adaptation^20,21 in alignment with the guidelines of the International Test Commission.²² A Spanish translation of the BAS²³ with adequate linguistic equivalency for the Spanish for Puerto Rico was available as determined by pre-testing this version in a sample of our patients.^20,21 It was determined that only the new items developed for the BAS-2 would undergo cross-cultural adaptation. In the first stage of phase one, three independent, bilingual speakers forward-translated the new five items of the BAS-2 from English into Spanish, for whom Spanish is their first language: one of them is a professional translator, naïve to the subject under investigation while two of them are researchers (Drs. Ana L Mulero-Portela and Graciela Vega-Debién) with experience in health studies. In the second stage, the three translators synthesized the three forward-translations through a consensual approach. In the third stage, two additional translators participated in the backward translation process of the Spanish for Puerto Rico synthesized version. These two translators are bilingual speakers, whose English is their mother tongue and who are naïve to the subject of the study; one of them is a professional translator. For the final stage of this phase, the two forward Spanish translations and the two backward English translations were discussed with the parent study’s research staff, including experts in research methodology and health professionals (physical therapists and psychologists), and the professional translators. A final version was produced after reaching a consensus.

The second phase consisted of the psychometric evaluation of the BAS-2. Informed consent was obtained from all eligible participants in person. Participants were interviewed on-site until March 2020. Due to the Covid-19 pandemic, interviews were conducted virtually using Zoom for Healthcare. Study data were collected and managed using REDCap (Research Electronic Data Capture). REDCap is a secure, web-based software platform designed to support data capture for research studies.^24,25 The scales were administered by a trained interviewer, who followed a standardized interviewing protocol. A trained interviewer administered the measures to ensure clarity, support, and completeness. Given the sensitive nature of the topics assessed (i.e. depression, body dissatisfaction), ethical considerations included the risk of emotional distress. The interviewer was trained to detect such signs and initiate the crisis management plan if needed. Adherence to the interviewing protocol was monitored during the study. A 20 US-dollar incentive was provided to the participants following the interview.

Data analysis

A descriptive analysis was conducted to examine the sample’s sociodemographic characteristics, including age, educational level, and clinical features. Only the data from the participants who completed all the items of the measures were included in the analysis as the number of incomplete cases was very small (n = 2).⁸ Internal consistency was assessed using Cronbach α coefficient. The convergent construct validity of the BAS-2 was measured using the Spearman correlation coefficient to assess the association between depression, mental health, and BMI. The Shapiro-Wilk test was used to check if the sample was normally distributed for the scales evaluated. Kaiser-Meyer-Olkin measure was performed to evaluate sampling adequacy and Barlett’s test of sphericity was used to evaluate the redundance of items. The exploratory factorial analysis (EFA) was conducted using the principal component analysis as the extraction method. Statistical analysis was performed using IBM 173 SPSS, version 25 (SPSS Inc., Chicago, Ill., USA).

Results

Phase 1: Cross-cultural adaptation of BAS-2

During the final stage of the cross-cultural adaptation process, only one item required further discussion, I appreciate the different and unique characteristics of my body, as in Spanish, the term appreciation can also be translated as value. The term appreciation ended up being chosen for the translation to denote enjoyment and gratitude of own uniqueness (Aprecio las características diferentes y únicas de mi cuerpo). Table 2 presents the finalized adaptation.

Table 2.

Cross-cultural adaptation BAS-2 Spanish version for Puerto Rico.

Instrucciones: A continuación, leerá algunas frases sobre pensamientos acerca de su cuerpo. Lea cada una de ellas y escoja la respuesta con la que mejor se identifica. Para cada ítem, use la siguiente escala: 1 = Nunca, 2 = Rara vez, 3 = A veces, 4 = A menudo, 5 =Siempre. No hay respuestas “buenas” ni “malas”.
1.	Respeto mi cuerpo.
2.	Me siento bien con mi cuerpo.
3.	Siento que mi cuerpo tiene al menos algunas cualidades buenas.
4.	Tengo una actitud positiva hacia mi cuerpo.
5.	Estoy atenta/o a las necesidades de mi cuerpo.
6.	Siento amor por mi cuerpo.*
7.	Aprecio las caracteristicas diferentes y únicas de mi cuerpo.*
8.	Mi comportamiento revela mi actitud positiva hacia mi cuerpo; por ejemplo, mantengo mi frente en alto y sonrío.*
9.	Estoy cómoda(o) en mi cuerpo.*
10.	Siento que soy bella/guapo incluso si soy diferente a las imágenes de personas atractivas en los medios de comunicación (ej. modelos, actrices/actores).*

^*Items that were cross-culturally adapted for this study.

Phase II: Psychometric evaluation of BAS-2

For this phase, 109 participants were recruited, with an average age of 60.9 years (SD = 7.1). Approximately half were single, divorced, or widowed. Sixty-four percent had an educational level of a bachelor’s degree or higher. Thirty-six percent of the participants had stage II breast cancer. Sociodemographic characteristics are presented in Table 3.

Table 3.

sociodemographic characteristics of participants from psychometric analysis of cultural adaptation of BAs-2

Variable (n = 109)	M ± SD / n (%)
Age	60.94 ± 7.15
Marital status
Single, divorced, widowed	52 (47.71)
Married or consensual union	57 (52.29)
Education
High-school or lower	6 (5.50)
Some university	13 (11.93)
Associated or technical degree	20 (18.35)
Bachelor’s degree	41 (37.61)
Post-graduate degree (MS, PhD)	29 (26.61)
Cancer stage
0	12 (11.01)
I	34 (31.19)
II	39 (35.78)
III	24 (22.02)

Body appreciation

The BAS-2 was completed by 109 participants. Body appreciation for the 10 items ranged from 4.02 to 4.82, with a M = 4.44 (SD = 0.64; Table 4).

Table 4.

Items in BAS-2.

Items in BAS-2 (n = 109)	M ± SD
1. I respect my body.	4.82 ± 0.48
2. I feel good about my body.	4.02 ± 1.00
3. I feel that my body has at least some good qualities.	4.47 ± 0.75
4. I have a positive attitude toward my body.	4.39 ± 0.86
5. I am attentive to my body’s needs.	4.56 ± 0.76
6. I feel love for my body.	4.55 ± 0.90
7. I appreciate the different and unique characteristics of my body.	4.37 ± 0.96
8. My behavior reveals my positive attitude toward my body; for example, I walk holding my head high and smiling.	4.66 ± 0.66
9. I am comfortable in my body.	4.28 ± 0.96
10. I feel like I am beautiful even if I am different from media images of attractive people (e.g. models, actresses/actors).	4.29 ± 0.98

Most of the responses had mean values above 4, with 84% of the participants answering that they ‘always’ respect their body and 72% answering that they ‘always’ feel love for their body and ‘always’ are attentive to their body’s needs (data not shown). Three-quarters of the participants responded that their behaviors ‘always’ reveal their positive attitude toward their body (for instance, I walk holding my head high and smiling).

Depression

One hundred eight participants answered all items of the Beck Depression Inventory-II. The M was 7.96 (SD = 6.87), a median of 6.00, with scores ranging from 0 to 32 (Table 5). The mean score indicates minimal depression in this sample.

Table 5.

Depression status BDI-II.

Depression status (n = 108)	n (%)
Minimal	74 (69)
Mild	24 (22)
Moderate	9 (8)
Severe	1 (1)

Mental health.

One hundred-eight participants completed the Global Mental Health; from these, one participant missed one item. The M was 51.82 (SD = 8.63). Ninety percent of participants reported their mental health, including mood and ability to think, as good and above (good 24%, very good 44%, and excellent 28%). Fifteen percent indicated that they had emotional problems such as anxiety, depression, or irritability (often 12%, always 3%).

Body mass index

BMI was calculated for 109 participants. BMI ranged from 19.27 to 50.63, with a M of 28.12 (SD = 5.80), a median of 26.94, and a mode of 30.21.

Internal consistency of BAS-2

The internal consistency of the cultural adaptation of the BAS-2 for Puerto Rican Spanish was Cronbach α=.92. All inter-item correlations, except one, demonstrated acceptable values (i.e. between .30 and .90).²⁶ The correlation between the items “I respect my body” with “I feel good about my body,” was .22 (Table 6). However, when the item “I respect my body” is deleted, the internal consistency did not markedly change. Thus, this item was preserved.

Table 6.

Correlation matrix of the Puerto Rican Spanish version of the BAS-2.

Items in BAs-2 (n = 107)	1	2	3	4	5	6	7	8	9	10
1. I respect my body.	1.00	.22	.29	.36	.36	.43	.37	.39	.36	.37
2. I feel good about my body		1.00	.44	.66	.46	.59	.63	.43	.73	.62
3. I feel that my body has at least some good qualities			1.00	.56	.35	.40	.49	.46	.49	.50
4. I have a positive attitude toward my body.				1.00	.52	.68	.74	.63	.72	.63
5. I am attentive to my body's needs.					1.00	.60	.53	.51	.44	.46
6. I feel love for my body.						1.00	.66	.56	.58	.58
7. I appreciate the different and unique characteristics of my body.							1.00	.61	.67	.63
8. My behavior reveals my positive attitude toward my body; for example, I walk holding my head high and smiling.								1.00	.62	.56
9. I am comfortable in my body.									1.00	.75
10. I feel like I am beautiful even if I am different from media images of attractive people (e.g. models, actresses/actors).										1.00

Construct validity

Exploratory factor analysis

The Bartlett’s test of sphericity was statistically significant (ꭕ² = 644.76, df = 45, p < 0.001) which means that the correlations among the variables are significantly different from zero. Likewise, the Kaiser-Meyer-Olkin value was 0.92, which indicates that sampling for factor analysis is adequate. The exploratory factor analysis indicated that the BAS-2 adapted for the Spanish of Puerto Rico is unidimensional. The single factor had an eigenvalue of 5.69 which explains 58.23% of the total variance of the scale. All items aside from item 1 (I respect my body) had communalities greater than 0.40, indicating that the items are an important part of the factor. Although item 1 had a communality of 0.27, the internal consistency of the BAS-2 remained excellent when this item was removed from the scale.

Convergent construct validity

The BAS-2, BDI-II, and PROMIS Mental Health subscale scores were not normally distributed (Shapiro-Wilk test, (p < 0.05). A significant negative correlation was observed between body appreciation and levels of depression symptomatology and between body appreciation and BMI (r = −0.46 and −0.29, respectively) (Table 7). On the other hand, a significant, positive correlation between body appreciation and mental health (r=.50) was noted. The intercorrelation matrix and descriptive statistics for the sample (n = 107) analyzed for convergent construct validity are presented in Table 8.

Table 7.

Paired correlations for convergent construct validity (n = 107).

combination	r (95% CI)
Body appreciation and levels of depression symptomatology	−0.46* (−0.60, −0.29)
Body appreciation and mental health	.50* (0.34, 0.63)
Body appreciation and BMI	−0.29** (−0.46, −0.11)

^*p < 0.001.

^**p = 0.007.

Table 8.

Inter-correlation matrix for convergent construct validity (n = 107).

construct (Instrument)	Mean	sd	1	2	3	4
1. Body appreciation (BAs2)	4.43	0.65	1.00	−0.46*	.50*	−0.29*
2. Depression (BDI-II)	7.96	7.01		1.00	−0.68*	.14
3. Mental Health (PROMIS Global Mental Health)	51.81	8.66			1.00	−0.11
4. Body Mass Index	28.12	5.80				1.00

^*p < 0.001.

Discussion

The mean obtained in the BAS-2 adapted for Puerto Rican Spanish was higher than the results obtained in studies from Hong Kong (M = 3.48, SD = 0.57),²⁷ Poland (M = 3.72, SD = 0.73),²⁸ and Argentina (M = 3.72, SD = 0.96);⁷ however, it was very similar to those from studies in Mexico (M = 4.11, SD = 0.81) and Colombia (M = 4.25, SD = 0.77)⁷ even though their participants were younger than the ones included in our study and included males. An explanation for the similar results is that since the last two study subjects were Hispanic, they may share some sociocultural similarities with the Puerto Rican Hispanics in our sample.

In Australia, a study involving 123 women diagnosed with breast cancer within five years reported a BAS-2 mean of 3.56 (SD = 0.81), lower than our study’s findings.²⁹ BAS-2 scores were notably higher among married women. However, due to our small sample size, we could not conduct additional comparisons based on demographic variables like marital status. A recent study introduced a tailored tool for assessing body acceptance among women with breast cancer,³⁰ highlighting higher levels of body appreciation among those in earlier stages or who had completed treatment—consistent with our sample, where all participants had concluded cancer treatment, primarily falling within cancer stages 0 to II. Conversely, our findings displayed a notable positive bias in responses, possibly influenced by higher levels of education and socioeconomic status—a trend observed in prior studies linking these factors to greater body image acceptance among breast cancer survivors.^31,32 With 70% of our sample holding a bachelor’s or post-graduate degree, this association is likely. Higher education and socioeconomic status may equip women with resources to navigate challenges associated with breast cancer, such as a better grasp of the condition’s effects, treatment expectations, and the financial capacity to access supportive services like psychological counseling, nutritional guidance, fitness programs, and cosmetic procedures. These resources could potentially contribute to a positive body image outlook. Further research is needed to examine this relationship and assess the impact of these factors.

Despite expectations of body image dissatisfaction and mental distress following breast cancer treatment, our sample exhibited elevated levels of body appreciation and mental well-being. This contrasts with previous research linking breast cancer interventions to adverse psychological outcomes like depression and anxiety.³³ Recognizing the impact of mental health on cancer outcomes, routine assessment of body image is strongly recommended.

Using the criteria set by Kline,³⁴ the internal consistency was considered excellent, which is consistent with the results obtained for other cultural adaptations of the BAS-2. Using EFA, all items were loaded onto a single factor, supporting the one-dimensionality of the BAS-2 for Puerto Rican Spanish, like the original BAS-2 psychometric evaluation and other Western cultural adaptations.³⁵ Our results show that the scores of the Puerto Rican cross-culturally adapted BAS-2 translated for the Spanish of Puerto Rico had good patterns of convergent validity. As predicted, a positive relationship was found between body appreciation and mental health. This suggests that women with a greater body appreciation score in our sample had a healthier perception of their mental health. The low depressive symptomatology, scores above the norm in mental health, and high body appreciation scores among the Puerto Rican women in our study may be explained by the fact that our sample consists of women highly motivated to include exercise in their rehabilitation. Findings from the parent study demonstrated that the sample reported high levels of intention to engage in physical activity as assessed by the “Theory of Planned Behavior Questionnaire” developed by Mulero-Portela et al.³⁶ The mean score for the intention in this sample was 6.86 (SD = 0.46) on a scale ranging from 0 to 7, where a higher score indicates a greater intention to exercise. This positive correlation between exercise and body image aligns with previous research by Tylka and Wood-Barcalow,³⁷ underscoring the interconnectedness of physical activity and body image perception.

Body appreciation was negatively associated with depression and BMI among the women in our study. Although this is in line with other studies^38–40 that have found correlations between body appreciation, body image, and depression, this study adds information on the convergent validity of the BAS-2 using the BDI-II. Our results agree with those described in a meta-analysis by He et al.³⁹ that examined the relationship between BMI and body appreciation, where a small to moderate correlation between these constructs was found. Another noteworthy finding from this meta-analysis pertained to the relationship between ethnicity and body appreciation. Our results support previous observations suggesting that Hispanic women, despite potentially higher BMI, tend to maintain a positive body image compared to non-Hispanic women, shedding light on cultural influences on body perception. This cultural context may explain the elevated BAS-2 scores observed in our sample.

This study extends the validation of the BAS-2 to a sample of Puerto Rican women aged 50 and older diagnosed with breast cancer, in contrast to most validation studies that have focused on young, healthy individuals. Breast cancer treatment can affect women’s bodies and how they perceive themselves, and in turn, affects their body image.⁴¹ As found in this study, body image and mental health are positively correlated. Emphasis should be placed on interventions aimed at promoting positive body image. Having a valid tool that could be used among women who are breast cancer survivors would assist researchers in testing the effect of such interventions. Thus, additional testing to advance the psychometrics of the BAS-2 on construct validity and test-retest reliability is recommended with larger samples of women with breast cancer.

Integrating this tool into routine clinical assessments could help identify survivors who might benefit from additional support. Healthcare professionals can incorporate discussions about body appreciation into counseling sessions, utilizing a variety of proven, cancer-specific interventions to enhance positive body image in women who have undergone breast cancer treatment. These interventions, which consider the biopsychosocial factors unique to the breast cancer population, may include guided imagery, self-compassion-based writing, and the “Accepting Your Body after Cancer” program, all of which have shown efficacy in addressing the unique body image concerns of breast cancer survivors.⁴²

Given that our sample size is relatively small and was a convenience sample of women who are breast cancer survivors aged 50 years and above, highly educated, and mainly from the metropolitan area of Puerto Rico, it is not representative of the Puerto Rican population. Height and weight were self-reported, which could have led to inaccurate BMI values. Because of our limited sample size, differences between sample subgroups were not assessed. Variables such as age, educational level, and interview mode could have impacted measurement. Previous research suggests that face-to-face interviews may lead to biased positive responses influenced by social desirability.⁴³ This bias has been observed among older individuals.⁴⁴ The relation between demographic characteristics and body appreciation among women who are breast cancer survivors merits additional research with larger samples.

Kling et al.³⁵ identified the need to conduct psychometric studies on the BAS or BAS-2 in clinical settings. Having this version of the BAS-2 for the Spanish of Puerto Rico would facilitate the assessment of this measure among patients with other health conditions, particularly in clinical practice. Additional research could also examine the psychometric properties and measurement invariance among countries in the Caribbean to facilitate cross-cultural comparisons and help uncover patterns among populations that are distinct from other Western populations. Future research should also consider quantifying the direct impact of other body image predictors, such as social and environmental factors, on positive body image. This could lead to better healthcare interventions that target specific factors among the population.

Conclusion

This study demonstrated that the BAS-2 adapted for Puerto Rican Spanish has excellent internal consistency. The construct validity findings showed a one-dimensional structure, and a negative association between body appreciation, depression, and BMI. A modest positive association was found between body appreciation and mental health. The BAS-2 adapted for Puerto Rican Spanish has adequate psychometric properties in a sample of women who are breast cancer survivors.