Mental health literacy and stigma towards eating disorders in Saudi Arabia: a cross-sectional study

Abstract

Background

Eating disorders (EDs) are complex mental health conditions influenced by genetic, psychological, and sociocultural factors. In Saudi Arabia, rising ED prevalence among youth underscores the need for early diagnosis, increased awareness, and targeted intervention. This study examined the relationship between Mental Health Literacy (MHL) and EDs stigma within the Saudi population.

Methods

Utilizing a cross-sectional design, data were collected from 370 participants across all Saudi provinces through a convenience sampling method. Data analysis was conducted by the R software version 4.2.2.

Results

Findings from this study showed generally high MHL and low to moderate stigma. There was a significant inverse relationship between MHL and stigma. Unadjusted linear regression indicated that higher MHL was associated with lower ED stigma. Other predictors of greater stigma included male gender, older age, being married, employment in the private sector, and higher income. Exposure to EDs, such as knowing someone with an ED or having self-diagnosed, was associated with reduced stigma.

Conclusions

The findings of this study underscore the central role of MHL in mitigating stigma toward EDs. Enhancing public education about EDs and promoting accurate understanding may reduce stigmatizing attitudes, improve early intervention, and support better health outcomes in Saudi Arabia.

Plain language summary

Eating disorders are mental health issues that affect people. In Saudi Arabia, more young people have these problems. We looked at the general population in Saudi Arabia to know how people understand mental health and how it is related to the stigma they may have toward eating disorders. We surveyed 370 people and found that they had a good knowledge of mental health and low to moderate stigma levels toward eating disorders. Interestingly, people with good mental health knowledge had low negative views about eating disorders. However, a group of people have negative views, such as men, older adults, married people, working in private jobs, and with higher incomes. People who had experience with eating disorders, like knowing someone with one or having one themselves, were to be less judgmental. Therefore, increasing awareness of mental health can help reduce the stigma related to eating disorders. This could lead to better support, quicker help for those affected, and healthier outcomes.

Introduction

EDs are serious mental health conditions marked by an unhealthy fixation on food, body image, and certain behaviors, often accompanied by emotional distress [1]. These disorders—such as anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant/restrictive food intake disorder have significant psychological, physical, and social repercussions [2]. Contributing factors to EDs include age, gender, socioeconomic status, and cultural background [3]. In Saudi Arabia, multiple studies have shown concerning ED prevalence among youth [4, 5].

The development of EDs is multifaceted, involving genetic, biological, psychological, environmental, and sociocultural influences [3]. Many individuals with EDs suffer from coexisting mental health conditions: approximately 50% have anxiety disorders, while 40% experience mood disorders [6]. Other risk factors include high Body Mass Index (BMI), depression, and restrictive dieting [7]. Physical consequences range from nutrient deficiencies and hormonal disturbances to cardiovascular complications [8]. EDs are also associated with chronic health conditions such as diabetes and celiac disease. For instance, women with BED show a higher prevalence of type-2 diabetes compared to healthy controls and men with EDs may also be prone to being overweight [9, 10].

Guided by the Health Belief Model (HBM) [11], this study conceptualizes ED-specific mental health literacy (MHL) as a key determinant of help-seeking behavior through its influence on stigma and health beliefs. Individuals with low ED-MHL may underestimate the severity of EDs, perceive fewer benefits of treatment, and anticipate higher barriers to accessing care. These beliefs can amplify both self-stigma and perceived public stigma, which in turn decrease intentions to seek professional help. We propose that ED-specific MHL functions as an upstream factor shaping perceived severity, benefits, and barriers, while simultaneously reducing stigma and facilitating more adaptive help-seeking behaviors.

Sociocultural pressures, including peer pressure, bullying, parental criticism, and internalized beauty standards, are central to the development of EDs [12]. In Saudi Arabia, the adoption of Western ideals of thinness has significantly impacted young women, leading to body dissatisfaction and disordered eating [13]. A study in Almadinah revealed that family impact and media-induced perceptions of body image and weight greatly contribute to eating disorders, with peer pressure also being a significant factor [14]. Similarly, another study highlighted social media and peer influence as major risk factors, with females being twice as likely as males to develop EDs. While peer influence was stronger among males, females were more affected by media exposure [15]. Despite the growing prevalence of EDs, early identification and intervention are frequently impeded by stigma, public misconceptions, which are related to a lack of MHL [4, 16].

In Saudi context, these risk factors are evident. Research on Saudi women found prevalence rates comparable to Western countries, with bulimic tendencies more frequent than anorexic ones. Western cultural assimilation has been strongly associated with EDs, body dissatisfaction, and comorbidities [17]. On a regional level, anorexia nervosa prevalence in in the Middle East and North Africa increased significantly between 1990 and 2019, marking EDs as a rising public health concern [18]. Moreover, traditional and religiously influenced gender norms shape Saudi women’s perceptions of the ideal body, reinforcing societal pressures [19].

The awareness and beliefs that support the recognition, management, or prevention of mental illness have been demonstrated to play a crucial role in diminishing stigma and promoting help-seeking behaviors [20, 21]. Female athletes, in particular, are vulnerable due to performance and aesthetic pressures [22]. Within families, factors such as high expectations and interpersonal conflicts can also act as stressors that contribute to the onset of EDs [4, 12]. emphasized the urgent need for national awareness programs and early intervention strategies targeted at young populations in Saudi Arabia.

MHL is defined as the knowledge and beliefs that enable the recognition, management, and prevention of mental illnesses [23]. In the context of EDs, MHL includes awareness of symptoms, risk factors, treatment options, and available resources. Grasping this dynamic via a Mental Health Literacy framework—knowledge and beliefs that support recognition, management, and prevention—helps clarify how insufficient disorder-specific literacy perpetuates stigma and limits access to care [24]. Studies show a strong link between MHL and positive nutritional and mental health behaviors [25, 26]. Low levels of ED-specific MHL (ED-MHL) can delay recognition and treatment-seeking behaviors [27, 28].

Stigma, often stemming from poor public understanding, remains a significant barrier to care. Individuals with EDs often encounter blame, judgment, or the misconception that their condition is self-inflicted or attention-seeking [29]. These societal attitudes foster self-stigma and internalized shame, discouraging people from seeking help and hindering recovery [30].

Despite the prevalence of EDs in Saudi Arabia, little research has examined public perceptions, MHL, and stigma. This study seeks to fill that gap by exploring the relationship between MHL, and stigma related to EDs in the Saudi population. Understanding these components is crucial for developing effective interventions, enhancing support systems, and improving mental health outcomes. This study provides a critical analysis of the relationship between MHL and stigma toward EDs within the Saudi context. By identifying public attitudes and misconceptions, the research can inform policymakers and healthcare professionals in crafting culturally appropriate awareness campaigns and treatment programs. The findings aim to reduce stigma, promote early intervention, and encourage treatment-seeking behaviors, ultimately leading to better health outcomes.

Method

Aim

The aim of this study was to investigate the relationship between MHL, and stigma related to eating disorders within the Saudi community.

Design and participants

This study used a cross-sectional descriptive design. A cross-sectional design facilitates the collection of data for all variables at a single time point, enabling the examination of multiple outcomes and exposures [31]. This study utilized a convenience sampling technique. Participants were selected based on their availability in convenient locations and times, without randomization. This approach was chosen for its practicality and accessibility, offering a cost-effective and time-efficient method of sampling [32]. This study took place in all of Saudi Arabia’s provinces. All provinces have been selected as data collection sites due to cultural and socioeconomic diversity. Data collection took place between August 2024, and December 2024. The distribution of all questionnaires was via Microsoft Forms through social media (X, WhatsApp, and Telegram). The study subjects were individuals who met the following inclusion criteria: Saudi citizens, willing to participate in the study, and 18 years old and above. Participants were excluded from the study if they were non-Saudi citizens or under 18 years old.

Sample size calculation

The sample size was determined to estimate the mean score of the primary outcome—ED stigma (EDSS)—with sufficient precision. Based on the method described by Daniel (1999) for estimating a population mean, the sample size was calculated using the formula:

where n is the required sample size, Z is the standard normal value for the desired confidence level, σ is the assumed standard deviation of the outcome, and d is the acceptable margin of error. Assuming a conservative standard deviation of 1.0, a 95% confidence level (Z = 1.96), and a precision of 0.1 points, the required sample size was estimated to be 385 participants. A total of 408 individuals were invited to complete the questionnaire, and responses were received from 370 eligible participants, resulting a response rate of 90.7%.

Data collection

Following the Institutional Review Board (IRB) approval from King Abdullah International Medical Research Center (KAIMRC). Respondents who agreed to participate were invited to respond to the survey questionnaire. The online survey included a cover page containing an invitation to participate in the study, as well as the study’s aims and objectives, followed by a consent form for individuals who decided to participate, and a sociodemographic questionnaire, with all tools that measure the variables. The estimated time for each participant to complete the survey was 10 to 15 min.

Measurements

Sociodemographic questionnaire

The demographic data will include age, gender, marital status, education level, employment status, income status, type of work, and sector.

Mental health literacy questionnaire short version adult (MHLq_SVa)

MHLq_SVa is a 16-item questionnaire with four defined MHL dimensions: knowledge, beliefs, help-seeking intentions, and self-help strategies [33]. The questionnaire has a five-point Likert scale, with responses ranging from 1 = strongly disagree to 5 = strongly agree. The overall score was obtained by summing all points, a higher score shows a sufficient MHL. The MHLq-SVa was reported in different cultures as a valid and reliable tool for assessing mental health [26]. The tool has good reliability (all Cronbach’s alphas > 0.80) [33].

In this study, the Arabic version was developed through translation and back translation by a bilingual expert, followed by face validity. Also, the Arabic version in this study demonstrated a good internal consistency, with a Cronbach’s alpha of 0.82 (95% CI: 0.77–0.86). Further, Cronbach’s alpha values were calculated for each subscale, which fell within acceptable levels for research purposes (Table 2).

Table 2.

Median scores for individual items and summary statistics for each MHLq-SVa dimension and total scale

Questions	Median (IQR)
Knowledge of mental health problems
Q7: Changes in brain function may lead to the onset of mental disorders.	4.0 (4.0–5.0)
Q10: One of the symptoms of depression is the loss of interest or pleasure in most things.	5.0 (4.0–5.0)
Q11: The symptom’s length is one of the important criteria for the diagnosis of a mental disorder.	4.0 (4.0–5.0)
Q12: Mental disorders affect people’s thoughts.	5.0 (4.0–5.0)
Q14: A person with schizophrenia may see and hear things that nobody else sees and hears.	4.0 (4.0–5.0)
Q15: Highly stressful situations may cause mental disorders.	5.0 (4.0–5.0)
Total Dimension Score
Sum (scale from 6 to 30)	25.6 ± 3.1
Average (scale from 1 to 5)	4.3 ± 0.5
Cronbach alpha (95% CI)	0.79 (0.74–0.86)
Erroneous beliefs/stereotypes
Q2: Mental disorders don’t affect people’s behaviors.	5.0 (4.0–5.0)
Q5: Mental disorders don’t affect people’s feelings.	5.0 (4.0–5.0)
Q6: Only adults have mental disorders	5.0 (4.0–5.0)
Total Dimension Score
Sum (scale from 3 to 15)	13.0 ± 2.2
Average (scale from 1 to 5)	4.3 ± 0.7
Cronbach alpha (95% CI)	0.63 (0.52–0.72)
Help-seeking and first aid skills
Q4: If I had a mental disorder I would seek for a psychologist’s help.	4.0 (3.0–5.0)
Q8: If someone close to me had a mental disorder, I would encourage her/him to see a psychiatrist.	4.0 (4.0–5.0)
Q16: If I had a mental disorder, I would seek for a psychiatrist’s help.	4.0 (4.0–5.0)
Total Dimension Score
Sum (scale from 3 to 15)	12.2 ± 2.2
Average (scale from 1 to 5)	4.1 ± 0.7
Cronbach alpha (95% CI)	0.78 (0.72–0.82)
Self-help strategies
Q1: Physical exercise contributes to good mental health.	5.0 (4.0–5.0)
Q3: Sleeping well contributes to good mental health.	5.0 (4.0–5.0)
Q9: A balanced diet contributes to good mental health.	4.0 (4.0–5.0)
Q13: Doing something enjoyable contributes to good mental health.	5.0 (4.0–5.0)
Total Dimension Score
Sum (scale from 4 to 20)	17.8 ± 2.1
Average (scale from 1 to 5)	4.5 ± 0.5
Cronbach alpha (95% CI)	0.71 (0.63–0.80)
MHLq Total
Sum (scale from 16 to 80)	68.6 ± 6.7
Average (scale from 1 to 5)	4.3 ± 0.4
Cronbach alpha (95% CI)	0.82 (0.78–0.87)

MHLq Item scores are reported as median (interquartile range, IQR). Total and dimension scores are reported as mean ± standard deviation (SD). All items were scored on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Cronbach’s α refers to internal consistency reliability for each dimension and the total scale

Eating disorder stigma scale (EDSS)

The EDSS questionnaire assesses stigma towards eating disorders [34]. It consists of 20 items on a 5-point Likert scale. The questions are divided into four sub-scales: Trivial, Selfish, Weak, and Blame. The questionnaire’s overall score is calculated by summing the responses to all 20 questions. The higher scores mean higher levels of stigma. The four subscales had good reliability (all Cronbach’s alpha > 0.80) [34]. Previous research reported acceptable internal consistencies for the scale (α = 0.86) [35].

The EDSS was translated from English to Arabic and back-translated by two professional translators. Overlapping items that have similar meaning were merged, resulting in a 10-item Arabic version to avoid redundancy. The Cronbach’s alpha in this study was calculated to assess internal consistency and demonstrate acceptable reliability (α = 0.77).

For the 10-item Arabic EDSS, face validity was established by a panel of five experts who assessed the clarity of the items. Content validity was assessed using the Content Validity Index (CVI). Five experts rated each item, with I-CVI values ranging from 0.60 to 1.00, and the overall S-CVI/Ave was 0.82, and nine items exceeded the 0.78 threshold, which indicates acceptable content validity. All tool permissions were obtained from the authors of the tools.

Statistical analysis

Descriptive statistics were used to summarize participant characteristics, MHLq, and EDSS scores. Continuous variables were reported as means and standard deviations (SD) if normally distributed, and as medians with interquartile ranges (IQR) for item-level Likert data. Categorical variables were summarized using frequencies and percentages.

Internal consistency of the MHLq-SVa and EDSS was assessed using Cronbach’s alpha, with 95% confidence intervals (CI) computed using bootstrapping methods. Pearson’s correlation coefficients (r) were used to assess the bivariate relationships between total and dimensional MHLq scores and EDSS scores.

To identify predictors of ED stigma, linear regression models were conducted. Unadjusted models examined the individual associations between EDSS and each predictor, including demographic variables (age, gender, marital status, education, employment, income), work sector, and four ED-related exposure variables. A multivariable linear regression model was then constructed to assess the adjusted associations, including all predictors simultaneously. Categorical variables were dummy-coded, and reference categories were clearly specified in each analysis. Statistical significance was set at p < 0.05. Effect estimates were presented as unstandardized regression coefficients (β), along with 95% CI and p-values.

All statistical analyses were performed using R software version 4.2.2. A two-tailed p-value < 0.05 was considered statistically significant.

Results

Participant demographics and exposure to eds

Table 1 presents the distribution of sociodemographic characteristics and self-reported experience or awareness of eating disorders among the 370 participants. The mean age was 31.8 years (SD = 13.1), with a range of 18 to 69 years. Most participants were between 21 and 30 years old (41.9%). The majority were female (77.3%) and single (54.3%). Regarding educational attainment, 62.4% held a bachelor’s degree, while 18.6% had a high school education or less. A large proportion were students (35.1%) or unemployed (24.9%). Nearly one-third (31.4%) reported working in the health sector. In terms of monthly income, 32.4% had no income, and 27.6% earned less than 5000 SAR. With respect to eating disorder-related exposure, 29.2% had interacted with a person diagnosed with an eating disorder (direct contact), and 24.3% reported knowing someone with an eating disorder (indirect contact). Only 5.7% reported having been personally diagnosed, whereas more than half (56.5%) expressed a need for increased awareness about eating disorders.

Table 1.

Sociodemographic characteristics and ED-related exposure among the study sample (n = 400)

Variable	Value
Age
Mean ± SD	31.8 ± 13.1
Range	18–69
Category
18–20	59 (15.9)
21–30	155 (41.9)
31–40	75 (20.3)
> 40	81 (21.9)
Gender
Female	286 (77.3)
Male	84 (22.7)
Marital status
Married	153 (41.4)
Single	201 (54.3)
Divorced	9 (2.4)
widow	7 (1.9)
Educational level
High school or less	69 (18.6)
Diploma	35 (9.5)
Bachelor’s degree	231 (62.4)
Master’s degree	25 (6.8)
Doctorate	10 (2.7)
Type of work
Student	130 (35.1)
Unemployed	92 (24.9)
Government employee	82 (22.2)
Private sector employee	50 (13.5)
Self-employed	16 (4.3)
Sector
Non health	254 (68.6)
Health	116 (31.4)
Income
None	120 (32.4)
< 5000 SAR	102 (27.6)
5000–10,000 SAR	47 (12.7)
> 10,000–15,000 SAR	51 (13.8)
> 15,000–20,000 SAR	30 (8.1)
> 20,000 SAR	20 (5.4)
Eating Disorder Awareness & Experience
Interacted ED Patient	108 (29.2)
Knows ED Patient	90 (24.3)
Self-Diagnosed ED	21 (5.7)
Need ED Awareness	209 (56.5)

Data are presented as n (%) unless otherwise indicated. Age is shown as mean ± standard deviation (SD) and range in years. Income categories are reported in Saudi Riyal (SAR). ED Awareness & Experience includes four binary (yes/no) items

Descriptive summary of MHL dimensions and items

Table 2 summarizes the responses to the 16 items of the MHLq-SVa, grouped by their corresponding dimensions. Median scores for individual items across all four factors were generally high, with most items receiving a median rating of 4.0 or 5.0. For the “Knowledge of mental health problems” dimension, the average score was 4.3 ± 0.5 out of 5, and internal consistency was acceptable (Cronbach’s α = 0.79; 95% CI: 0.74–0.86). The “Erroneous beliefs/stereotypes” dimension showed a similar mean of 4.3 ± 0.7 but with lower internal consistency (α = 0.63; 95% CI: 0.52–0.72). Scores on “Help-seeking and first aid skills” were slightly lower (mean = 4.1 ± 0.7), with good reliability (α = 0.78; 95% CI: 0.72–0.82). The “Self-help strategies” dimension had the highest average score (4.5 ± 0.5) with moderate internal consistency (α = 0.71; 95% CI: 0.63–0.80). Overall, the average MHLq score was 4.3 ± 0.4 out of 5, with strong reliability (α = 0.82; 95% CI: 0.78–0.87), indicating generally high levels of mental health literacy in the sample.

Descriptive summary of EDSS items

Table 3 presents summarizes participants’ responses to the 10-item short version of the Eating Disorder Stigma Scale (EDSS), which represents the four original stigma domains: Trivialization, Selfish/Vain, Weakness, and Blame. Median scores for items across these domains generally reflected low to moderate agreement. For example, trivializing beliefs such as the idea that ED is less serious than other illnesses received a median of 3.0 or below. Items reflecting views that individuals with EDs are selfish or vain (e.g., “They only care about themselves”) also showed median scores of 2.0 to 3.0. Statements implying character weakness (e.g., “Their eating disorder represents a weakness in their character”) and blame (e.g., “They are responsible for their eating disorder”) showed similar response patterns. The average total EDSS score was 2.6 ± 0.6, and internal consistency was acceptable (Cronbach’s α = 0.77; 95% CI: 0.73–0.81), suggesting overall low levels of stigma among participants, with some variability across domains.

Table 3.

Median scores for individual stigma items and overall summary statistics

Questions	Median (IQR)
Trivial
Q1: Their illness is not as serious as other mental illnesses.	3.0 (2.0–4.0)
Q2: Their illness is not as serious as other physical illnesses.	2.0 (2.0–3.0)
Q3: The pain caused by their eating disorder is not as important as other people’s pain.	2.0 (2.0–3.0)
Selfish/Vain
Q4: They only care about themselves.	2.0 (2.0–3.0)
Q5: They are obsessed with looking like supermodels.	3.0 (2.0–4.0)
Weak
Q6: Their eating disorder represents a weakness in their character.	3.0 (2.0–4.0)
Q7: They are unintelligent and should know better.	3.0 (2.0–3.0)
Q8: They are pathetic for not being able to control their eating disorder.	2.0 (2.0–3.0)
Blame
Q9: They are responsible for their eating disorder.	3.0 (2.0–3.0)
Q10: They are not to blame for their condition. (Reversed)	2.0 (2.0–3.0)
Total EDSS Score
Sum (scale from 10 to 50)	25.9 ± 6.1
Average (scale from 1 to 5)	2.6 ± 0.6
Cronbach alpha (95% CI)	0.77 (0.73–0.81)

EDSS item scores are reported as median (interquartile range, IQR). Total EDSS scores are reported as mean ± standard deviation (SD). Items were rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Item Q10 was reverse-coded prior to score computation. Cronbach’s alpha reflects internal consistency reliability with 95% confidence intervals (CI)

Correlation between MHL and eds stigma

Figure 1 displays the bivariate relationships between eating disorder stigma and mental health literacy. The top panel shows a significant negative correlation between the total MHLq score and the EDSS total score (r = -0.38, p < 0.001), indicating that participants with higher mental health literacy reported lower levels of stigma. The bottom panels break this association down by MHLq dimensions. Strongest inverse associations were observed for knowledge of mental health problems (r = -0.38, p < 0.001) and erroneous beliefs/stereotypes (r = -0.36, p < 0.001). A weaker, yet significant, correlation was found for first aid skills and help-seeking behavior (r = -0.20, p < 0.001), while the association with self-help strategies was weak and did not reach statistical significance (r = -0.09, p = 0.080).

Fig. 1.

Correlation Between MHL and ED Stigma. Scatter plots with linear regression lines illustrating the relationship between total and dimensional scores of MHLq and EDSS. The total MHLq score showed a moderate negative correlation with EDSS (r = -0.38, p < 0.001). Among the MHLq dimensions, knowledge of mental health problems (r = -0.38, p < 0.001) and erroneous beliefs/stereotypes (r = -0.36, p < 0.001) were most strongly associated with lower stigma. First aid skills and help-seeking behavior showed a weaker but significant correlation (r = -0.20, p < 0.001), while self-help strategies were not significantly associated (r = -0.09, p = 0.099)

Unadjusted and adjusted regression analyses of EDSS scores

Table 4 displays the results of unadjusted and adjusted linear regression analyses examining predictors of stigma toward eating disorders. In the unadjusted analysis, higher mental health literacy scores were associated with lower EDSS scores (β = -0.55; 95% CI: -0.69 to -0.42; p < 0.001), while higher age was associated with higher stigma (β = 0.01; 95% CI: 0.01 to 0.02; p < 0.001). Compared to females, males reported higher EDSS scores (β = 0.33; 95% CI: 0.18 to 0.47; p < 0.001). Relative to married individuals, single participants had significantly lower stigma (β = -0.38; 95% CI: -0.50 to -0.26; p < 0.001), while no differences were observed for divorced or widowed participants. In terms of education, diploma holders reported higher stigma compared to those with high school or less (β = 0.27; 95% CI: 0.02 to 0.52; p = 0.031), whereas no significant differences were found for other educational levels. Compared to the unemployed, students had lower EDSS scores (β = -0.33; 95% CI: -0.48 to -0.17; p < 0.001) and private sector employees had higher EDSS scores (β = 0.22; 95% CI: 0.02 to 0.42; p = 0.029). Working in the health sector was associated with lower stigma than working outside health (β = -0.26; 95% CI: -0.40 to -0.13; p < 0.001). Participants with higher income levels reported greater stigma compared to those earning less than 5000 SAR. Specifically, those earning > 10,000–15,000 SAR (β = 0.35; 95% CI: 0.15 to 0.55; p < 0.001), 15,001–20,000 SAR (β = 0.24; 95% CI: 0.00 to 0.49; p = 0.049), and more than 20,000 SAR (β = 0.31; 95% CI: 0.02 to 0.60; p = 0.036) demonstrated higher EDSS scores, while no differences were found for participants earning 5000–10,000 SAR or those with no income. Participants who had interacted with an ED patient (β = -0.20; p = 0.004), knew someone with an ED (β = -0.22; p = 0.002), or had self-diagnosed (β = -0.33; p = 0.018) all reported lower EDSS scores than those who had not.

Table 4.

Sociodemographic and exposure predictors of ED stigma: linear regression results

Predictor	Mean ± SD	Unadjusted		Adjusted
		β (95% CI)	p	β (95% CI)	p
MHLq Total	r = -0.38	-0.55 (-0.69 to -0.42)	< 0.001	-0.45 (-0.59 to -0.31)	< 0.001
Age	r = 0.29	0.01 (0.01 to 0.02)	< 0.001	0.00 (-0.00 to 0.01)	0.460
Gender
Female	2.5 ± 0.6	Reference		Reference
Male	2.8 ± 0.6	0.33 (0.18 to 0.47)	< 0.001	0.10 (-0.07 to 0.26)	0.241
Marital status
Married	2.8 ± 0.5	Reference		Reference
Divorced	2.9 ± 0.7	0.10 (-0.29 to 0.49)	0.626	-0.00 (-0.37 to 0.37)	0.997
Single	2.4 ± 0.6	-0.38 (-0.50 to -0.26)	< 0.001	-0.25 (-0.43 to -0.07)	0.006
widow	2.6 ± 0.6	-0.18 (-0.62 to 0.26)	0.427	-0.15 (-0.58 to 0.27)	0.477
Education
High school or less	2.6 ± 0.5	Reference		Reference
Diploma	2.9 ± 0.5	0.27 (0.02 to 0.52)	0.031	-0.04 (-0.29 to 0.20)	0.745
Bachelor’s degree	2.5 ± 0.6	-0.07 (-0.23 to 0.09)	0.410	-0.12 (-0.27 to 0.04)	0.143
Master’s degree	2.7 ± 0.7	0.10 (-0.18 to 0.38)	0.480	-0.17 (-0.45 to 0.11)	0.224
Doctorate	2.7 ± 0.7	0.10 (-0.30 to 0.50)	0.633	-0.13 (-0.53 to 0.28)	0.544
Type of work
Unemployed	2.7 ± 0.5	Reference		Reference
Government employee	2.7 ± 0.6	-0.02 (-0.19 to 0.15)	0.837	0.03 (-0.22 to 0.27)	0.837
Private sector employee	2.9 ± 0.5	0.22 (0.02 to 0.42)	0.029	0.29 (0.04 to 0.54)	0.022
Self-employed	2.7 ± 0.4	0.05 (-0.25 to 0.36)	0.734	-0.03 (-0.35 to 0.29)	0.843
Student	2.3 ± 0.6	-0.33 (-0.48 to -0.17)	< 0.001	-0.11 (-0.29 to 0.08)	0.267
Sector
Non-health	2.7 ± 0.6	Reference		Reference
Health	2.4 ± 0.7	-0.26 (-0.40 to -0.13)	< 0.001	-0.03 (-0.16 to 0.11)	0.721
Income
< 5000 SAR	2.5 ± 0.6	Reference		Reference
5000–10,000 SAR	2.6 ± 0.6	0.14 (-0.06 to 0.35)	0.171	-0.17 (-0.40 to 0.06)	0.147
> 10,000–15,000 SAR	2.8 ± 0.6	0.35 (0.15 to 0.55)	< 0.001	-0.06 (-0.31 to 0.19)	0.661
> 15,000–20,000 SAR	2.7 ± 0.6	0.24 (0.00 to 0.49)	0.049	-0.13 (-0.42 to 0.15)	0.350
> 20,000 SAR	2.8 ± 0.6	0.31 (0.02 to 0.60)	0.036	-0.10 (-0.44 to 0.25)	0.583
None	2.5 ± 0.6	0.06 (-0.10 to 0.22)	0.439	-0.02 (-0.17 to 0.13)	0.775
Eating Disorder Awareness & Experience
Interacted ED Patient
No	2.6 ± 0.6	Reference		Reference
Yes	2.4 ± 0.7	-0.20 (-0.33 to -0.06)	0.004	-0.01 (-0.20 to 0.17)	0.891
Knows ED Patient
No	2.6 ± 0.6	Reference		Reference
Yes	2.4 ± 0.6	-0.22 (-0.37 to -0.08)	0.002	-0.11 (-0.31 to 0.09)	0.274
Self-Diagnosed ED
No	2.6 ± 0.6	Reference		Reference
Yes	2.3 ± 0.8	-0.32 (-0.59 to -0.06)	0.018	-0.12 (-0.38 to 0.14)	0.374
Need ED Awareness
No	2.6 ± 0.6	Reference		Reference
Yes	2.6 ± 0.6	-0.06 (-0.18 to 0.07)	0.379	-0.06 (-0.17 to 0.06)	0.328

Values are presented as β coefficients with 95% CI and corresponding p-values. r refers to the Pearson correlation coefficient between each continuous predictor and the EDSS score. SAR = Saudi Riyal. Statistically significant p-values (p < 0.05) are presented in bold and italics in the table

In the adjusted analysis, higher mental health literacy remained the strongest independent predictor of lower stigma (β = -0.45; 95% CI: -0.59 to -0.31; p < 0.001). Compared to married participants, singles continued to show lower stigma (β = -0.25; 95% CI: -0.43 to -0.07; p = 0.006), and private sector employees continued to show higher stigma relative to the unemployed (β = 0.29; 95% CI: 0.04 to 0.54; p = 0.022). All other associations became statistically non-significant after adjustment, including age, gender, sector, income, and ED-related exposure.

Discussion

This study demonstrated a significant inverse association between MHL and stigma toward EDs in Saudi Arabia (r = -0.37, p < 0.001). Participants with higher MHL scores reported substantially lower stigma levels, which aligns with previous international findings showing that literacy enhances empathy and reduces prejudicial attitudes toward individuals with mental illness, including EDs [29, 36, 37]. The results highlight MHL as a central protective factor that mitigates negative stereotypes and promotes supportive attitudes, consistent with Jorm’s conceptualization that improving mental health literacy strengthens recognition, management, and prevention of mental disorders [24] Guided by the HBM, our results further suggest that ED-specific MHL may shape stigma and help-seeking intentions by influencing perceived severity, benefits, and barriers. Regression analysis confirmed that MHL remained the strongest predictor of reduced stigma, even after adjusting for sociodemographic variables. This is consistent with prior reviews emphasizing the effectiveness of education-based interventions in stigma reduction [37, 38]. Interestingly, marital status and occupational sector emerged as significant predictors, with single participants reporting lower stigma than married ones. Younger, unmarried individuals may be more exposed to progressive health narratives via social media and globalized communication [13, 39]. Occupational settings and stigma private sector employees demonstrated higher stigma compared to the unemployed, while no significant difference was found for government workers after adjustment. Although these findings should be interpreted cautiously, they suggest that workplace culture may play a role in shaping stigma. Competitive, performance-driven environments typical of the private sector may reinforce stigma by linking mental illness to weakness or inefficiency [40]. In contrast, public-sector employment, with its greater job security and less market-driven culture, may foster comparatively less stigma. Similar international evidence indicates that occupational environments strongly influence attitudes toward mental health, with stigma more prevalent in hierarchical or male-dominated workplaces [40]. Future Saudi-based research should compare public and private organizational cultures more systematically, as this distinction could have important implications for workplace-based interventions. Cultural and historical context of body image ED stigma in Saudi Arabia is also shaped by the evolution of body image ideals. Historically, fuller body shapes were associated with health, fertility, and social prosperity in Arab societies [19]. However, modernization and increased exposure to Western cultural norms have shifted beauty ideals toward thinness, especially among young women [5, 36]. Research among Saudi undergraduates has confirmed that Westernization is associated with increased body dissatisfaction and higher ED risk [5]. Social media has further intensified these pressures, exposing youth to thin-ideal portrayals and equating attractiveness with success [38, 41]. At the same time, conservative Saudi values rooted in religion and family honor contribute to stigma by framing EDs as weakness, vanity, or a failure of self-control [42, 43]. This intersection of modern and traditional influences explains why stigmatizing beliefs in this study frequently centered on personal blame and weakness, reflecting both global and local cultural patterns [28, 44]. Further insights are offered by the relationship between specific MHL domains and ED stigma. Strong inverse correlations were observed for knowledge of mental health problems and erroneous beliefs/stereotypes, indicating that factual understanding and the rejection of misconceptions are critical for reducing stigma. This is supported by international research showing that correcting misinformation is one of the most effective pathways to stigma reduction [28, 29]. The weaker yet significant association between stigma and help-seeking/first-aid skills suggests that while recognizing the importance of professional care reduces stigma, structural and cultural barriers continue to limit actual help-seeking in Saudi Arabia [43, 45]. In contrast, self-help strategies such as diet, sleep, and exercise were not significantly related to stigma, consistent with evidence that lifestyle awareness does not directly challenge prejudicial attitudes [27, 46]. These findings highlight the need for anti-stigma interventions to prioritize the knowledge and beliefs dimensions of MHL while promoting culturally acceptable models of professional help-seeking. Taken together, these findings align with the HBM conceptual model: ED-MHL appears to reduce stigma by modifying perceived severity, benefits, and barriers, while stigma itself acts as a mediator that suppresses help-seeking behaviors. Thus, anti-stigma interventions in Saudi Arabia should not only provide accurate information about EDs but also target cultural beliefs and workplace environments that amplify barriers.

The findings of this study have several implications for nursing practice. Nurses must be equipped for the early detection and screening of EDs, especially among young adults. Additionally, community-based nursing is in a vital position to deliver MHL and anti-stigma education beyond clinical settings. Launch nationwide campaigns using traditional and digital media to educate the public about EDs, their causes, and the importance of early intervention. Campaigns should be culturally tailored to Saudi values, involving respected community and religious leaders. Promote anti-stigma training and MHL workshops within corporate and public institutions to cultivate inclusive environments. School and university programs should integrate ED-related mental health education into secondary and tertiary curricula. Encourage open discussions about body image, media influence, and emotional health.

Limitations

Although the findings of this study provided valuable insight, several limitations must be acknowledged. A cross-sectional design limits the ability to explore causality between EDs stigma and MHL. Further research is needed to conduct a longitudinal study to confirm that enhancing MHL directly leads to reducing stigma over time. Self-administered tools could lead to social bias, where participants may overestimate their mental health knowledge or underreport stigmatizing topics. The generalizability of the study is limited due to convenience sampling that does not represent a wider Saudi population and likely involved more educated participants.

Another limitation of this study is that we did not perform exploratory or confirmatory factor analysis to assess the underlying structure of the Arabic-translated, reduced 10-item version of EDSS. As the scale was used solely as a unidimensional measure to generate a total stigma score, without interpretation of subscales, internal consistency using Cronbach’s alpha was deemed sufficient to assess reliability. Nonetheless, future research is encouraged to examine the factorial structure of the shortened version to further validate its construct integrity in the Arabic-speaking context. Future research could study the differences in mental health literacy and stigma between participants across provinces, as this study was imitated by collecting province-specific data in Saudi Arabia.

Abbreviations

EDs

Eating disorders

MHL

Mental Health Literacy

IRB

Institutional Review Board

MHLq_Sva

Mental Health Literacy Questionnaire Short Version Adult

EDSS

Eating Disorder Stigma Scale

CVI

Content Validity Index

Biographies

Samirh Said Alqhtani

PhD, PMHNP-BC, MSN, RN, is an Assistant Professor, Psychiatric Mental Health Nursing, College of Nursing at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Ministry of National Guard Health Affairs (MNGHA), Riyadh, Saudi Arabia.

Joud Lutfi Bakheet

Nursing Intern Student, KSAU-HS.

Hend Abdu Alnajjar

PhD, RN, is an Associate Professor in Pediatric Nursing and the Dean of the College of Nursing at KSAU-HS, MNGHA, Jeddah, Saudi Arabia.

Seham Alselami

PhD, MSN, RN is an Assistant Professor in Medical and Surgical Nursing, College of Nursing at KSAU-HS, MNGHA, Jeddah, Saudi Arabia

Sawsan Kamal Khalil Elgalad

Assistant Professor, Psychiatric and Mental Health Nursing, College of Nursing, KSAU-HS, MNGHA, Jeddah, Saudi Arabia. Lecturer, Department of Psychiatric and Mental Health Nursing, Alexandria University, Alexandria, Egypt

Author contributions

SSA supervised the research process and contributed significantly to the writing and final revision of the manuscript. All researchers participated in data collection and data analysis. JLD contributed to drafting the manuscript. HAA and SEA contributed to the study’s design, data collection, and manuscript editing and revision. SKKE contributed to the writing of a discussion. All authors read and approved the final manuscript.

Funding

There was no funding provided for this study.

Data availability

All data analyzed are presented in this article.

Declarations

Ethics approval and consent to participate

In accordance with the Declaration of Helsinki, this study was approved by the Ethical Committee of King Abdullah International Medical Research Center (KAIMRC) IRB # (NRJ24/018/5- 0000065224). An online informed consent was obtained from all participants. Participants were informed that participation was voluntary and were assured of anonymity and confidentiality of the responses.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.