Modern Plastic Surgery, 2013, 3, 51-56
http://dx.doi.org/10.4236/mps.2013.32010 Published Online April 2013 (http://www.scirp.org/journal/mps) 51
Translation and Validation of the Nepalese Version of
Derriford Appearance Scale (DAS59)
Varun Pratap Singh1*, R. K. Singh2, T. P. Moss3, D. K. Roy4, D. D. Baral5
1JJT University, Jhunjunu, India; 2Department of Prosthodontics, College of Dental Surgery, B.P. Koirala Institute of Health Sciences,
Dharan, Nepal; 3Department of Psychology, University of the West of England, Bristol, UK; 4Dental Surgeon, Dharan, Nepal;
5Department of Community Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal.
Received November 23rd, 2012; revised December 26th, 2012; accepted January 2nd, 2013
Copyright © 2013 Varun Pratap Singh et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Objectives: To establish a valid and reliable translated version of Derriford Appearance Scale (DAS59) for Nepali
population. Methods: A standard translation-back-translation procedure was used followed by evaluation of semantic,
conceptual and society equivalence by the committee and changes were made according to recommendations. This cor-
rected version was pretested and a final version was developed. A validation study was performed using the final ver-
sion on 424 patients including 212 patients with clinical appearance problems and similar number of young adults who
had no concern for facial appearance. Reliability was assessed by Cronbach’s alpha value and test-retest correlation
coefficient. Discriminate and convergent validity were assessed by comparison between clinical and normal population
and correlation with Beck’s Anxiety Inventory (BAI), Beck’s Depression Inventory (BDI) and General Health ques-
tionnaire (GHQ). Results: The results indicated excellent internal consistency (Cronbach’s alpha = 0.98) and good test-
retest reliability (0.91 for clinical population, 0.86 for normal population). The Discriminate validity was good with
statistically significant differences between clinical and normal population. The convergent validity was confirmed
by good correlation with other related psychometric tools. Conclusion: A valid and reliable Nepali DAS59 version
was developed which can be used for research and clinical assessment of patients with appearance problems and con-
cerns.
Keywords: Derriford Appearance Scale; Reliability; Tran slation; Validation
1. Introduction
Attractiveness is a visual cue that people use to make
assumptions and conclusions about the personality and
behavior of others in once-off encounters and it can in-
fluence how we treat other. In modern society, physical
beauty is perceived as a personal characteristic and is
valued as such in its own right, independent of other
traits [1]. The general consensus is that attractiveness
does impact upon how others perceive individuals, such
that attractive individuals are associated with more posi-
tive social attributes and characteristics. It appears from
the literature that society judges an individual’s personal
characteristics from their outward appearance at a very
young age. An individual’s physical appearance is asso-
ciated with their inward character so that what is beauti-
ful on the outside is also perceiv ed to be beautiful on the
inside. The “beautiful equals good” stereotype prevails
[2-7].
Disfigurement and deformity is associated with nega-
tive social and psychological effects [8-11]. The psycho-
logical aspects of a deformity should not be underesti-
mated, daily social interactions for those with problems
of appearance is a source of unremitting stress, anxiety
and anguish, all of which have implications for personal-
ity functioning and mental health [11]. Individuals often
have to endure negative social reactions from other mem-
bers of the public ranging from stares and whispers to
ridicule and alienation, with the result that they are so-
cially disadvantaged and can be psychologically dam-
aged. As a result one of the most common responses of
individuals with disfigurement is to withdraw from social
interaction [12]. Appearance problems are often associ-
ated with an altered self-image, and decreased self-es-
teem [13-15].
*Corresponding a uthor.

Translation and Validation of the Nepalese Version of Derriford Appearance Scale (DAS59)
52
As appearance problems and concerns have shown to
be associated with psychological, psychosocial problems
and adjustments, it is very important to assess the psy-
chological distress and psychological adjustment in sub-
jects with appearance concerns. Further it could be useful
in case of surgical procedure to assess changes pre and
postoperatively [16]. There are various psychometric
tools available to measure psychological impact and ad-
justment of appearance such as the Appearance Schemas
Inventory [17], the Body Image Avoidance Question-
naire [18] and the Body Dysmorphic Disorder Examina-
tion [19], but they suffer from low content validity, re-
stricted range of applicability, impracticability or limited
psychometric development. None of these measures were
designed specifically to assess the spectrum of sympto-
matology that is relevant to the wide range of difficulties
experienced by patients living with problems of appear-
ance; therefore, the scales lack sen sitivity to the nature of
the dysfunctions an d the sev erity of th e distress that th ese
patients experience [16].
The Derriford Appearance Scale was specifically de-
signed for measuring the psychosocial adjustment in pa-
tients with appearance problem. This scale had demon-
strated excellent reliability and validity and had been
used in general population with no appearance concern,
general population with appearance concern and clinical
population with appearance problems. There are two
versions of scale—a short version which consists of 24
items basically meant for routine use in clinical practice
and a elaborate 59 item version meant for research and
detailed assessment [20-22]. This scale had demonstrated
excellent psychometric properties when translated and
validated internationally [23,24]. Before applying any
psychometric tool to different ethnic population settings
it should be translated, validated and adapted according
to local cultural and social needs. Therefore the aim of
this study was to develop a valid and reliable Nepalese
version of Derriford appearance sacle (DAS59).
2. Materials and Methods
2.1. Translation of DAS59
The DAS59 is copyright protected and translation pro-
cedure to be followed is listed in the website. First of all
permission is taken regarding translation from the de-
veloper then the tool was subjected to conceptual, se-
mantic and society equivalence. This was done by a
committee comprising of a clinical psychologist, ortho-
dontist, general surgeon, Public health specialist, mem-
bers of the civil society and members of the target popu-
lation. The committee suggested following changes: 1)
Change the options in the question “your ethnic back-
ground” as Nepal has different ethnicity than UK; 2) To
add religion also, because many religious practices are so
unique here that it can affect the outcome; 3) To include
Caste also according to demographics of Nepal; 4) Ques-
tion 37 refers to the beach, Nepal is a land-lock country
with no seashores, and instead we replaced it by swim-
ming. However there was a repeat [HOW DISTRESSED
DO YOU GET WHEN, item 37 You go to swim (as
modified from you go to the beach)], [HOW DIS-
TRESSED ARE YOU BY, item 45 Not being able to go
swimming], but the committee that both sections are dif-
ferent and a repeat can be justified, as the meaning of the
question changes in both sections, first section, says
about self consciousness because of swimwear. Second
section emphasize on the stress which he/she gets when
he/she is not able to go to swimming due to his/her “fea-
ture”, whereas many of his/her friends are going for
swimming.
Then a discussion was organized with the committee
members and members of the target population. The re-
placement item were then finalized and communicated to
the developer of the scale for approval, later with the
consent of developer new items were included.
We followed the standard translation-back translation
procedure as mentioned by the developer with translation
by an individual whose first language is English but has
good knowledge and command of Nepali language, fa-
cilitated by the fact that Dharan, Nepal is the hub of Brit-
ish Gurkhas and as many of them are settled in UK from
generations. We could find such people whose first lan-
guage is English and they well versed with Nepali too
because of their Nepali origin. Two individuals did trans-
lation independently and then it was synthesized by a
third translator. Now the translated version was back
translated by two individuals independently whose first
language is Nepali, but they are well versed in English,
we selected three English language teachers from various
Arts colleges. Two of them did the back translation in-
dependently and third synthesized it into one version.
This version was compared with original translation for
conceptual and semantic equivalence and with discussion
with committee members, translators the final version
was made. This final version was then pretested in the
target population, two interviewers—one orthodontist
and clinical psychologist administered the questionnaire
to 50 individuals from both the groups. We asked each
individual to read each item and try to explain the inter-
viewer about their interpretation of that question. There
were no confusing items and the subjects were readily
able to understand all items and the final Nepali version
was ready.
2.2. Administration of the Nepali Version of
DAS59
2.2.1. Derriford Appearance Scale (DAS59)
The DAS59 is presented as a series of 59 statements and
questions with response categories in a Likert format to

Translation and Validation of the Nepalese Version of Derriford Appearance Scale (DAS59) 53
measure frequency of symptomatology (“almost never” …
“almost always”) and levels of associated distress (“not
at all distressed” … “extremely distressed”). An intro-
ductory section gathers relevant demographic informa-
tion and identifies the aspect of appearance that is of
greatest concern to the respondent. This is referred to as
the respondent’s “feature” in the body of the scale. It also
identifies any other aspects of appearance about which
the respondent may also be concerned. Fifty-seven items
assess relevant psychological distress and dysfunction,
and two items assess physical distress and physical dys-
function. The format of the introductory section and a
“not applicable” response category for most items make
the scale acceptable to respondents who are not con-
cerned about appearance such as those in the general
population.
Actually clear and concise instructions are given on
how to complete the scale, which is designed as a self-
report questionnaire to be completed without supervision
but in this study subjects were asked to complete the
questionnaire in the presence of administrator, however
the administrator did not interfere with privacy of the
patient. The DAS59 generates six measures of psycho-
logical distress and dysfunction (an overall, full-scale
score and five factorial scores) as well as a measure of
physical distress and dysfunction (items 25 and 26). The
five domains are 1) General self-consciousness of ap-
pearance (GSC); 2) Social self-consciousness of appear-
ance (SSC); 3) Sexual and body self-consciousness of
appearance (SBSC); 4) Negative Self concept (NSC); 5)
Facial self-consciousness of appearance (FSC) [25].
General Health Questionnaire (GHQ12): This is a 12
items scales that is used to asses mental health status
especially in detection of emotional disorders such as
distress. The scoring is done on a likert scale. The trans-
lated and validated Nepali versio n is available [26].
Beck’s Anxiety Inventory (BAI) and Beck’s Depres-
sion Inventory (BDI): These 21 items scales are used to
assess depression and anxiety symptoms. Items are scor-
ed on a likert scale. The translated and validated Nepali
version is available [27,28].
2.2.2. Sample Siz e Calculation
The sample size of internal consistency for the Cron-
bach’s alpha was calculated by using Bonnett’s Formula
[29] with an alph a of 0.05 and a power of 90%, a sample
size of 133 subjects would be required. In order to allow
a 10% missing data rate at least 146 subjects should be
invited.
Ethical clearance was obtained from Institutional ethi-
cal review board and guidelines from declaration of Hel-
sinki were f ollowed.
2.2.3. Cl i n ical Sample
Adult patients with appearance problems were identified
from hospital record comprising developmental or ac-
quired disfigurement, these included craniofacial disfig-
urement (both developmental and acquired), post trau-
matic scarring, post burn scarring, mastectomy patients
reporting for secondary treatment due to appearance
concern. We were able to retrieve records of 300 pa tients
aged between 18 - 29 (Mean 23.08 ± 1.69). All were in-
vited for the study; of these two hundred twelve (70%)
agreed to participate in the study. There were 111 fe-
males and 101 males.
2.2.4. Non Cli ni c al Sampl e
Similar numbers of young adults between 18 - 29 (Mean
23.13 ± 2) years of age were recruited conveniently from
Dharan municipality, Dharan City, Nepal who were not
concern about their appearance. There were 112 males
and 100 females. In this way a total of 424 patients were
asked to complete the questionnaire in the calm univer-
sity hospital settings in the presence of one investigator
who did not interfere with the privacy of the patient.
There were 211 females and 213 males. Out of total 50
patients were selected randomly for test-retest analysis
from each group.
The questionnaire cons isted of
1) Nepali version of DAS consisting of 59 items. Each
item response is marked based on a four point likert
scale from 1 to 4 with 1 indicating “almost never” and
4 indicate “almost always”.
2) General Health Questionnaire (GHQ12) consisting of
12 items. Each item response is marked based on a
four point likert scale from 1 to 4 with 1 indicating
“not at all” and 4—“much more than usual”. A vali-
dated Nepali Version was available and was used.
3) Beck’s Anxiety Inventory (BAI) and Beck’s Depres-
sion Inventory (BDI): Consisting of 21 items each. In
BAI each item response is marked based on a four
point likert scale from 1 to 4 with 1 indicating “not at
all” and 4—“severely, I could barely stand it”. In BDI
each item response is marked based on a four point
likert scale from 1 to 4. Validated Nepali versions
were available and were used.
3. Statistical Analysis
The data was entered in SPSS Version 19. Reliability of
the scale was tested by Cronbach’s alpha coefficient and
coefficient of correlation. The retest reliability was also
tested using Spearman’s correlation coefficient between
items and scale total score.
Discriminant validity was tested by assessing the dif-
ferences between those who are not concerned about
facial appearance and those who seek treatment for
problems of appearance using Mann-Whitney test. Con-
vergent validity was tested by assessing the correlation
between DAS59 with GHQ12, BDI and BAI scales.

Translation and Validation of the Nepalese Version of Derriford Appearance Scale (DAS59)
54
4. Results
Reliability: The scale demonstrated good reliability and
internal consistency as shown by overall Cronbach’s al-
pha value of 0.985 and corrected inter-item correlation
values between 0.57 to 0.81. The Cronbach’s alpha if
item deleted showed that deleting an item will not in-
crease the Cronbach’s alpha hence all the items to be
retained. Domain wise, the Cronbach’s alpha of 0.95,
0.95, 0.90, 0.88, 0.85 respectively with corrected inter-
class coefficient ranging from 0.53 to 0.85, 0.60 to 0.77,
0.57 to 0.76, 0.55 to 0.81 and 0.64 to 0.72 respectively
(Table 1).
4.1. Test-Retest Reliability
The scale total test-retest correlation coefficient was 0.91
for clinical population and 0.86 for the normal population
not concerned about appearance.
4.2. Validity
Face and Content Validity
Face validity was good as confirmed by the expert com-
mittee consisting of orthodontist, clinical psychologist;
epidemiology expert and members of the target popula-
tion; further review of literature also confirmed the face
validity.
Discriminant validity was confirmed by the significant
differences between the subjects with no concern for
appearance and those with reported problems of appear-
ance (Table 2). Convergent validity was confirmed by
significant correlation between this scale and BDI, BAI,
GHQ12 scales. (The correlation coefficient ranged from
0.69 to 0.76) (Table 3).
5. Discussion
This study describes the translation and validation of
DAS59 into Nepali. The translation procedure is already
Table 1. Shows no of items in each domain along with Cron-
bach’s alpha if item deleted and corrected inter class corre-
lation between the domains [*1) General self-consciousness
of appearance (GSC); 2) Social self-consciousness of ap-
pearance (SSC); 3) Sexual and body self-consciousness of
appearance (SBSC); 4) Negative Self concept (NSC); 5)
Facial self-consciousness of appearance (FSC)].
Domain No. of
items Cronbach’s alpha Corrected item— total correlation
GSC* 17 0.95 0.53 to 0.85
SSC* 20 0.95 0.60 to 0.72
SBSC* 09 0.90 0.57 to 0.76
NSC* 05 0.88 0.55 to 0.81
FSC* 04 0.85 0.64 to 0.72
Table 2. Differences between domains, main scale and other
scales against grouping variables-patients who are not con-
cerned about their appearance and those with appearance
problems by using Mann-Whitney U Test.
Scale and domainsMann-Whitney U Asymp. sig. (2-tailed)
DAS59 567.00 0.000*
GSC 955.500 0.000*
SSC 550.00 0.000*
SBSC 1393.500 0.000*
NSC 984.00 0.000*
FSC 614.00 0.000*
PHY 2818.00 0.000*
OTH 2953.00 0.000*
BDI 480.500 0.000*
BAI 784.00 0.000*
GHQ 1291.00 0.000*
*Correlati on is significant at the 0.001 level.
Table 3. Showing significant correlation between DAS59,
BDI, BAI and GHQ12.
Total BDI BAIGHQ
Correlation
coefficient 1.000 0.760 0.7310.748**
DAS59
Sig (2-tailed) - 0.000 0.0000.000
Correlation
coefficient 0.760 1.00 0.7620.693**
BDI
Sig (2-tailed) 0.000 0.000 0.0000.000
Correlation
coefficient 0.748 0.693 0.698 1.000
Spearman’s
rho
GHQ
Sig (2-tailed) 0.000 0.000 0.0000.000
**Correlation is significant at the 0.001 level.
explained in detail in the methodo logy section. The over-
all internal consistency was excellen t (α = 0.98) and was
equal to that of the o riginal article that first described the
scale [16]. There was good correlation between all the
items representing a good homogeneity. Domains also
demonstrated good internal consistency and correlation
within themselves. The test-retest reliability was also
good.
The Construct validity of the Nepali DAS59 was as-
sessed under convergent and Discriminant validity. Dis-
criminant validity was demonstrated by highly signifi-
cant differences between the clinical population having
appearance concern and nonclinical population with no
facial concern. Convergent validity was confirmed by
significant correlation between DAS59, BDI, BAI and
GHQ.

Translation and Validation of the Nepalese Version of Derriford Appearance Scale (DAS59) 55
6. Conclusion
A reliable and valid Nepali version of DAS59 was de-
veloped to measure the psychological impact and ad-
justment for use in subjects with problems of appearance.
7. Acknowledgements
The authors thank Mr. David Harris and Mr. Tony Carr
whose ideas lead to the development of the Derriford
Appearance Scale. The authors thank Dr. Brandon Kohrt
for his valuable help in providing translated and vali-
dated Nepali versions of GHQ-12, BDI, BAI. Further the
authors acknowledge Dr. D.D. Agarwal, Hon. Vice-
chancellor, JJT University and Dr. Om Prakash of the
same university for their valuable suggestions.
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