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VOLUME 6, ISSUE 1 

 2023 

 

RESEARCH ARTICLE 

Khani A, Babaee T, Khaghani A, Nakhaee M, Fatahi Z, Moss T. Reliability and validity testing of the Persian version of the Derriford Appearance Scale 24 in a 

sample of individuals with craniofacial irregularity and amputation. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.3. 

https://doi.org/10.33137/cpoj.v6i1.41454 

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https://doi.org/10.33137/cpoj.v6i1.41454


 

1 

Khani A, Babaee T, Khaghani A, Nakhaee M, Fatahi Z, Moss T. Reliability and validity testing of the Persian version of the Derriford Appearance Scale 24 in a 
sample of individuals with craniofacial irregularity and amputation. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v6i1.41454 

 

 

RESEARCH ARTICLE 

 

RELIABILITY AND VALIDITY TESTING OF THE PERSIAN VERSION OF THE DERRIFORD 

APPEARANCE SCALE 24 IN A SAMPLE OF INDIVIDUALS WITH CRANIOFACIAL 

IRREGULARITY AND AMPUTATION 

Khani A1, Babaee T2 *, Khaghani A2, Nakhaee M3, Fatahi Z1, Moss T4 

1 Department of Orthotics and Prosthetics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.  
2 Rehabilitation Research Center, Department of Orthotics and Prosthetics, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran.  
3 Department of Rehabilitation, Faculty of Allied Medicine, Kerman University of Medical Sciences, Kerman, Iran.  
4 Centre for Appearance Research, University of the West of England, Bristol, UK.  

  

 

 

 

 

  

 

 

 

 

 

 

 

 
 

INTRODUCTION   

Disfigurement can be defined as a visible difference or 

unusual appearance as a result of a mark, rash, scar, or 

graft on a person’s skin or an asymmetry or paralysis to a 

person’s face or body.1 Disfigurement might occur due to 

congenital malformation, traumatic events, and disease 

processes.2 Traumatic amputation, amputation due to 

Diabetes Mellitus and burn injuries are among the leading 

causes of disfigurement in low to middle-income 

countries.3,4 Despite the recent advancements in the design 

and manufacture of prostheses to improve their natural size, 

shape, and movement, prosthesis users may become self-

conscious about their appearance.5 This is partly due to the 

judgment and stigma they experience in their daily life.6  

The extent to which the disfigurement affects one’s 

perception of his/her appearance depends on two main 

factors.7 The first factor which is mainly social and cultural, 

which include social cues and feedback one might get from 

others. Disfigured individuals are usually less involved in 

social activities and tend to be isolated from society. The 

second factor is the individual’s self-perception determined 

by the impact of appearance on one’s perception of self-

concept, emotional well-being, and quality of life. Being 

 
OPEN  ACCESS 

ABSTRACT 

BACKGROUND: Despite the recent advancements in the design and manufacture of prostheses for 

individuals with craniofacial irregularity and amputation, these individuals tend to become self-conscious 

about their appearance. The aim of this study was to investigate the reliability and validity of Persian version 

of the Derriford Appearance Scale24 (P-DAS24) for a sample of individuals with craniofacial irregularity 

and limb loss. 

METHODOLOGY: Reliability of the P-DAS24 was determined by computing internal consistency and test-

retest reliability utilizing Cronbach’s alpha coefficient and Pearson’s correlation coefficient. Discriminant 

validity was investigated with comparing the total score of the P-DAS24 between disfigured participants 

and those with no appearance problem. Known-groups validity was evaluated regarding the participants’ 

gender and their level of involvement. 

FINDINGS: The sample size comprised of 251 individuals with disfigurement and 101 without disfigurement 

who were deemed normal in appearance. The P-DAS24 showed satisfactory internal consistency 

(Cronbach’s alpha = 0.89) and excellent test-retest reliability (r = 0.96). The total score of the P-DAS24 

showed a statistically significant difference between individuals deemed disfigured or normal (P=0.01). The 

total scores P-DAS24 in individuals with different levels of involvement were significantly different 

(P<0.001). The scores of the DAS2, DAS18, DAS21, and DAS24 were significantly different between men 

and women (P<0.01, <0.01, 0.03, and 0.01, respectively). 

CONCLUSION: The P-DAS24 is a valid and reliable tool that may be utilized in clinical practice and 

researches to assess the outcomes of prosthetic reconstructions in individuals with disfigurement. 

ARTICLE INFO 

Received: August 22, 2023 

Accepted: November 10, 2023     

Published: November 24, 2023 

CITATION 

Khani A, Babaee T, Khaghani 

A, Nakhaee M, Fatahi Z, Moss 

T. Reliability and validity testing 

of the Persian version of the 

Derriford Appearance Scale 24 

in a sample of individuals with 

craniofacial irregularity and 

amputation. Canadian 

Prosthetics & Orthotics Journal. 

2023; Volume 6, Issue 1, No.3. 

https://doi.org/10.33137/cpoj.v6i

1.41454 

KEYWORDS 

Appearance, Disfigurement, 

Craniofacial defect, Amputation, 

Prosthesis, Rehabilitation 

 

* CORRESPONDING AUTHOR: 

Taher Babaee, PhD, Rehabilitation Research Center, Department of 
Orthotics and Prosthetics, School of Rehabilitation Sciences, Iran 
University of Medical sciences, Tehran, Iran.  

Email: babaee.t@iums.ac.ir 

ORCID ID: https://orcid.org/0000-0002-1487-2374 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

Volume 6, Issue 1, Article No.3. 2023 

 

 

https://doi.org/10.33137/cpoj.v6i1.41454
https://doi.org/10.33137/cpoj.v6i1.41454
https://doi.org/10.33137/cpoj.v6i1.41454
mailto:babaee.t@iums.ac.ir
https://orcid.org/0000-0002-1487-2374
https://jps.library.utoronto.ca/index.php/cpoj/index


 

2 

Khani A, Babaee T, Khaghani A, Nakhaee M, Fatahi Z, Moss T. Reliability and validity testing of the Persian version of the Derriford Appearance Scale 24 in a 
sample of individuals with craniofacial irregularity and amputation. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v6i1.41454 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE PERSIAN VERSION OF THE DERRIFORD APPEARANCE SCALE 24 
Khani et al., 2023 

different from others might lead to feelings of shame, lower 

self-esteem, and appearance consciousness.7,8 

Facially or physically disfigured individuals encounter more 

psychosocial problems in their daily lives than individuals 

deemed attractive.9 Social stereotypes have led to the 

general assumption that physically attractive adults have 

more socially appealing personalities and live more fulfilling 

lives than those of lesser attractiveness.10 Furthermore, 

they receive more attention and social support in childhood 

and adulthood.11 On the other hand, disfigured individuals 

experience anxiety, discomfort, and alienation from other 

members of society.12  

Psychological adjustment to the injury and disfigurement is 

a challenging phase when returning to society7 as social 

discomfort and body image anxiety is relatively higher in 

some people with amputation than individuals without 

amputation.13 Based on data of a study published in 2021, 

a total of 57.7 million people were living with limb loss 

globally.14 Therefore, it is of paramount importance for the 

therapist/clinician to understand the psychosocial factors 

affecting one’s adaptation process to disfigurement/ 

amputation to adopt the most effective therapeutic 

approach and navigate a better restoration of body 

identity.15 Various psychometric tools have been developed 

to assess the psychological impact and adjustment of 

appearances such as the Appearance Schemas 

Inventory,15 the Body Image Avoidance Questionnaire,16 

and the Body Dysmorphic Disorder Examination.17 These 

questionnaires lack the necessary sensitivity to the nature 

of the irregularity and were not specifically designed to fully 

cover the spectrum of symptoms relevant to the wide range 

of difficulties experienced by individuals with 

disfigurement.12 Given the complexity of how an 

appearance difference might affect one’s social interaction 

and the resulting distress, the measure for this assessment 

should be well-standardized and psychometrically robust in 

order to fully capture the distress and dysfunction arising 

from body-image disturbance.18 

The Derriford Appearance Scale (DAS) is a valid and 

factorial scale that examines the psychosocial adjustment 

issues of subjects with a visible difference.18 This 

questionnaire examines the negative emotions of people 

with facial problems (such as fear, social anxiety, and 

shyness) and negative behaviors such as isolationism that 

may affect their lifestyle.19 DAS is available in two versions: 

DAS59 and the short form of DAS24. DAS24 specifically 

assesses appearance-related distress and dysfunction. In a 

study of 525 individuals with appearance problems, the 

DAS24 total score showed excellent internal consistency 

and concurrent validity with the DAS59.19 The DAS24 

questionnaire is suitable for patients on the plastic surgery 

list, people with cutaneous acne, neurofibromatosis, and 

eczema and it has formerly been used in a wide range of 

individuals who had appearance-related issues in different 

parts of their body.20 The questionnaire has also been 

widely used to assess general population facial concerns.20 

Although the Persian version of DAS59 was made available 

by Sadeghi-Bazargani et al.,9 the lengthy nature of the 

DAS59 has made its use time-consuming. Routine data 

collection in clinical practice and measurement of distress 

when there is a severe lack of time necessitates validation 

of its short form with the same sensitivity and improved time 

efficiency. The robust nature of DAS24 has made this 

questionnaire a more user-friendly and brief instrument for 

clinicians to evaluate the therapeutic outcome of the 

treatment process of individuals with disfigurement.17  

The DAS24 has so far been translated into Taiwanese,21 

Brazilian/Portuguese22 and Italian.23 It should be noted that 

both versions of DAS59 and DAS24 are available in Italian 

language.23,24 Given the ethnic, linguistic, and cultural 

differences between different communities that can 

influence how patient-centered questionnaires are 

completed, it is necessary to conceptually translate and 

validate the text of the questionnaire and confirm its 

reliability and validity to use scales such as DAS24. Also, in 

order to improve the generalizability and proper use of this 

instrument for individuals using cosmetic or functional 

prosthesis, this study was aimed at providing the Persian 

version of the DAS24 for a sample of individuals with 

craniofacial irregularity and limb loss.  

METHODOLOGY 

Translation and Cultural Adaptation 

The process of cultural adaptation of the DAS24 was 

conducted using the guidelines introduced by Beaton et al.25 

There were five main stages of forward translation, 

synthesizing of translations, backward translation, expert 

committee revision and the pre-final trial run (Figure 1). Prior 

to initiation of the study, permission to translate and 

culturally adapt the DAS24 was obtained from the developer 

via email. The study protocol was approved by the research 

ethics committee of Kerman University of Medical Sciences 

(Ref: # IR.KMU.REC.1399.413, date: 27/07/1399). The final 

Persian version of the DAS24 is available as a 

supplementary file.  

Participants and Sampling 

A convenience sample of 352 participants were enrolled in 

this study. 251 of whom had a disfigurement at some level 

and 101 individuals were normal and not visibly different. 

The disfigurement group had a discernible difference either 

in their appearance or daily function with the prosthesis. The 

inclusion criteria for the disfigurement group included: 1) 

being 18 or older, 2) having had facial amputation or limb 

loss with detectable dissimilarity, 3) having used a 

prosthesis for at least 3 months, 4) being able to read and 

write in Persian.  

https://doi.org/10.33137/cpoj.v6i1.41454


 

3 

Khani A, Babaee T, Khaghani A, Nakhaee M, Fatahi Z, Moss T. Reliability and validity testing of the Persian version of the Derriford Appearance Scale 24 in a 
sample of individuals with craniofacial irregularity and amputation. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v6i1.41454 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE PERSIAN VERSION OF THE DERRIFORD APPEARANCE SCALE 24 
Khani et al., 2023 

The research was conducted in two Orthotics and 

Prosthetics clinics which were referral centers for patients 

from all over Iran. Data collection was carried out from 

November 2021 to August 2022. The sample included those 

who had lost their body parts due to trauma (accidents, 

war), cancer, diabetes, burn, vascular disease or the cause 

of their disfigurement was congenital. The survey was filled 

either in person or online. Before filling in the questionnaire, 

subjects were provided a consent form to sign. For the 

online version, an invitation message was sent via 

WhatsApp which included a brief description of the study 

and a link to the questionnaire. Consent was obtained 

through the inclusion of a statement embedded at the 

beginning of the online survey. The phone number of the 

respondents were automatically removed by the software 

used (https://porsline.ir). The participants remained 

anonymous through the statistical analyses. 

The Derriford Appearance Scale 24 

The DAS24 is a twenty-four-item instrument aimed to 

assess the anxiety and impairments that results from 

abnormalities in one’s appearance.26 The first page of the 

scale consists of two parts. The upper section includes the 

demographic information, and the lower section determines 

the body part(s) that has disturbed the participants’ 

appearance. The primary section of the questionnaire 

includes 24 items. Some of the items are presented with 4 

and some are presented with 5 responses. For items a, b, 

d, h, j, n, q, t, and v the scores range from 1 (minimum 

discomfort) to 4 (maximum discomfort). The remaining 14 

items are given scores from 0 (not applicable) to 4 

(maximum discomfort). Thus, the minimum score for a 

respondent in DAS24 is 11 and the maximum is 96. The 

greater the score, the more self-conscious one feels about 

his/her appearance.  

Data analyses Reliability 

Reliability of the Persian version of DAS24 (P-DAS24) were 

assessed by computing internal consistency and also test-

retest reliability. Internal consistency or homogeneity of a 

scale represent the relationship between the score of each 

individual item and the total score.27 Test-retest reliability is 

to assess the reproducibility of the same scores for a scale 

over repeated trials. To investigate the test-retest reliability 

of the P-DAS24, a sample of 39 participants (19 cases with 

transtibial amputation, 9 with transfemoral amputation, 7 

with craniofacial irregularity, 3 with Syme disarticulation, 

and 1 with knee disarticulation) were randomly asked to 

complete the scale once again with the time interval of 2 

weeks. For internal consistency assessment of the P-

DAS24, Cronbach's alpha coefficient was used. Satisfactory 

internal consistency is determined by a value of 0.70 ≤ alpha 

≤ 0.95 for Cronbach’s alpha.28 To investigate the 

relationship between respective item of the P-DAS24 with 

the entire scale, the values of “Corrected Item-total 

Correlation” was evaluated. The value of higher than 0.3 

was deemed that each item has an agreeable relationship 

with the entire questionnaire.28 “Cronbach’s alpha if item 

deleted” was run to verify whether the extent of the 

Cronbach’s alpha increased since eliminating one item of 

the questionnaire. To assess the test retest reliability, the 

Pearson correlation coefficient analysis was used. 

Discriminant validity 

Discriminant validity is known as the ability of an instrument 

to differentiate between individuals with disfigurement and 

 

Figure 1: The cultural adaptation process of the Persian-DAS24. 

Forward translation

Two native Persian-speaking
interpreters who were fluent in
English translated the original
English version of the DAS24
into Persian.

Synthesis of Translations

The two interpreters
compared the two Persian
versions and reached a final
forward translated draft of
the questionnaire

Backward translation

The translated version of the questionnaire was then
translated to English by two native English-speaking
interpreters who were fluent in Persian. The two versions
were compared and any discrepancy was resolved via
discussion. The back-translated version of the
questionnaire was also approved by the developer of the
DAS24.

Expert committee review

The translated English version of the DAS24 and the Original version
were compared to find a semantic, idiomatic, experiential, and
conceptual equivalence between the Persian and the original versions
of the DAS24. Having compared the questionnaires and resolved the
discrepanciess, the Persian version of DAS24 was obtained for the trial
run.

Testing the pre-final version

The comprehensibility of the Persian-DAS24 was assessed by
asking 30 participants to complete the scale and report any
confusion in the provided items. The Confusing items were then
revised to enhance the understandability of the questionnaire for
community-dwelling individuals.

https://doi.org/10.33137/cpoj.v6i1.41454


 

4 

Khani A, Babaee T, Khaghani A, Nakhaee M, Fatahi Z, Moss T. Reliability and validity testing of the Persian version of the Derriford Appearance Scale 24 in a 
sample of individuals with craniofacial irregularity and amputation. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v6i1.41454 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE PERSIAN VERSION OF THE DERRIFORD APPEARANCE SCALE 24 
Khani et al., 2023 

the normal participants.27 In this study, discriminant validity 

of P-DAS24 was assessed by conducting a comparison of 

the P-DAS24 total score between disfigured participants 

and those with no appearance problem using Mann-

Whitney U test. 

Known-groups Validity 

In this technique, an instrument is deemed valid if it shows 

different scores for groups which are known to have 

different characteristics.27 We assessed the known-groups 

validity of the P-DAS24 regarding the gender of participants 

and their level of involvement (maxillofacial, upper limb 

amputation, transtibial amputation, knee disarticulation, 

transfemoral amputation, and partial foot amputation/ankle 

disarticulation using Kruskal-Wallis analysis of variance. 

Previous studies have shown that the gender and site of 

involvement affects individual’s response to the DAS24 

questionnaire.19,21,22 For the purpose of this study and to 

gain more reliable statistical results, individuals with 

involvements at eye, ear, nose and jaw were grouped as 

maxillofacial. Also, the amputees with partial foot and rear-

foot amputations were grouped as partial foot amputation/ 

ankle disarticulation. Moreover, those with transtibial 

amputation, knee disarticulation, and transfemoral 

amputation were categorized in their own group.  

Descriptive statistical information was reported by mean 

and standard deviation (SD). The relationship between the 

P-DAS24 total score and time since amputation and time 

using prosthesis was investigated using Spearman 

correlation coefficient. 

A threshold of 0.05 was considered as the statistical 

significance level with 95% confidence intervals for all 

correlation coefficients. All statistical analysis was 

conducted using the SPSS software program version 24 

(SPSS Inc., USA). 

RESULTS 

Participants 

The sample size comprised of 251 individuals with 

disfigurement and 101 without disfigurement who were 

deemed normal in appearance. The average age of the 

participants was 38.49 years old.  

Of the disfigured individuals, 201 (80%) were men. War-

related traumatic amputation and accidents were the 

leading causes of disfigurement accounting for 37.8% and 

35.1% of the disfigured population.  

Participants’ level of disfigurement was seen at different 

levels with transtibial amputation (44.2%) being the first 

followed by transfemoral amputation (18%), maxillofacial 

irregularities (11.9%), Syme amputation (11.5%), upper 

limb amputation (10%) and knee disarticulation (4.4%). The 

demographics of participants is revealed in (Table 1). 

Table 1: Demographic and clinical characteristics of the studied 

population (n=251). 

N (%) Variables 
Cause of problem 

16 (6.4) Diabetes  

88 (35.1) Accidents 

95 (37.8) War-related traumatic amputation 

11 (4.4) Cancer 

18 (7.2) Congenital 

23 (9.2) Burn  

Level of appearance problem 

30 (11.9)  Maxillofacial  

25 (10.0) Upper limb amputation 

45 (18.0) Transfemoral 

11 (4.4) Knee disarticulation 

111 (44.2) Transtibial 

29 (11.5) Partial foot and ankle amputation 

Occupational status 

191 (76.1) Working 

21 (8.3) Unemployed 

6 (2.4) Student 

28 (11.1) Homemaker 

5 (2.0) Missing  

Family status 

177 (70.5) Married 

34 (13.5) Living with relatives 

37 (14.7) Living alone 

3 (1.2) Missing 

Educational status 

50 (19.9) High school 

99 (39.4) Diploma 

56 (22.3) Bachelor 

34 (13.5) Master 

10 (4.0) PhD 

2 (0.8) Missing 

 

Reliability 

The P-DAS24 demonstrated excellent internal consistency 

(Cronbach’s alpha = 0.89). Regarding corrected item-total 

correlation, our results showed that items DAS8, DAS10, 

and DAS15 had a value < 0.3. Still, the Cronbach’s alpha if 

item deleted was exceeding 0.7 for the whole P-DAS24. 

Cronbach’s alpha if item deleted and Corrected Item Total 

Correlation scores confirmed that removing an item will not 

improve the value of Cronbach’s alpha, therefore all of the 

items were maintained (Table 2).  The scale total score of 

the P-DAS24 showed excellent test-retest reliability (r=0.96) 

(Table 2).  

Discriminant Validity 

The total score of the P-DAS24 showed a statistically 

significant difference between individuals deemed 

disfigured or normal (P=0.01).  

However, scores of items DAS2, DAS3, DAS5, DAS9, 

DAS10, DAS11, DAS13, DAS14, DAS15, DAS18, DAS21, 

DAS23, DAS24 did not appear to have a significant 

difference between the two groups (P>0.05, 0.55, 0.10, 

0.97, 0.06, 0.44, 0.64 0.08, 0.57, 0.14, 0.25, 0.65, 0.35, 

respectively) (Table 3). 

 

https://doi.org/10.33137/cpoj.v6i1.41454


 

5 

Khani A, Babaee T, Khaghani A, Nakhaee M, Fatahi Z, Moss T. Reliability and validity testing of the Persian version of the Derriford Appearance Scale 24 in a 
sample of individuals with craniofacial irregularity and amputation. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v6i1.41454 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE PERSIAN VERSION OF THE DERRIFORD APPEARANCE SCALE 24 
Khani et al., 2023 

Known-groups Validity 

The total scores of DAS24 for individuals with different 

levels of involvement were significantly different (P<0.001). 

Also, the scores of each item in P-DAS24 were shown to be 

significantly different with regard to the level of involvement 

except for DAS8 and DAS15 (P>0.89 and >0.60, 

respectively). Although the total score did not indicate a 

statistically significant difference regarding the gender of the 

individuals (P=0.67), the scores of the DAS2, DAS18, 

DAS21, and DAS24 were significantly different between 

men and women (P<0.01, <0.01, 0.03, and 0.01, 

respectively) (Table 3). 

The results of Spearman Correlation Coefficient analysis 

revealed no statistically significant relationship between 

time since amputation, time using prosthesis and DAS total 

score (P>0.05). 

DISCUSSION 

This study was set out to validate and cross-culturally adapt 

the Persian translated version of the DAS24 in a sample of 

individuals with upper and lower limb amputations and 

maxillofacial irregularities. Overall, the P-DAS24 

demonstrated satisfactory reliability. Therefore, the P-

DAS24 is a valid and reliable tool for the clinical evaluation 

of the appearance-related distress, anxiety and self-

consciousness experienced by individuals with visual 

difference on a daily basis in Persian speaking countries. 

The DAS24 is a unidimensional scale extracted from the 

DAS59 which generates a full-scale score in five factorial 

subscales of general self-consciousness of appearance, 

social self-consciousness of appearance, negative self-

concept, sexual and bodily self-consciousness of 

appearance and facial self-consciousness of 

appearance.11,19 

The total score of the P-DAS24 showed acceptable internal 

consistency as reflected by the Cronbach’s alpha which was 

0.89. This was similar to the internal consistency of the 

Original English version,19 the Brazilian/Portuguese,22 and 

the Italian version23 of the DAS24 (Cronbach’s alpha= 0.92, 

0.94, 0.93, respectively). Our results were similar to that of 

the Persian DAS59 which revealed excellent internal 

consistency (Cronbach’s alpha = 0.93).9 In that study, 

participants had suffered a burn injury in the face, head, ear, 

neck, hand and legs, however, the individuals in our study 

had disfigurements due to amputation. Regarding the item-

total correlation, the statistical analysis revealed that items 

8, 10, and 15 of the P-DAS24 were less than the cut-off 

value of 0.3. However, as confirmed by the results of 

Cronbach’s alpha if items are deleted, all P-DAS24 items 

were associated with the entire scale (Cronbach’s alpha > 

0.7).   

Table 2: Descriptive statistics and results of the reliability analyses: test-retest reliability (n=39) and internal consistency (n=251). 

Abbreviations: DAS = Derriford appearance scale; SD = standard deviation. 

 
DAS24 Items 

Mean (SD) 
Corrected Item-Total 

Correlation 
Cronbach’s Alpha If Item 

Deleted 

Pearson’s correlation 
coefficient for test-retest 

reliability  

DAS1 1.77 (0.84) 0.50 0.73 0.90 (0.82-0.94) 

DAS2 1.90 (1.08) 0.63 0.73 0.99 (0.98-0.99) 

DAS3 1.04 (1.05) 0.65 0.73 0.91 (0.84-0.95) 

DAS4 2.99 (1.04) 0.51 0.73 0.93 (0.87-0.96) 

DAS5 1.24 (1.15) 0.65 0.73 0.93 (0.87-0.96) 

DAS6 1.76 (1.44) 0.50 0.73 0.97 (0.95-0.98) 

DAS7 1.57 (1.17) 0.43 0.73 0.94 (0.89-0.96) 

DAS8 2.21 (1.23) 0.19 0.74 0.88 (0.79-0.94) 

DAS9 1.07 (1.08) 0.63 0.73 0.90 (0.82-0.95) 

DAS10 2.53 (0.96) 0.19 0.74 0.86 (0.75-0.92) 

DAS11 1.30 (0.64) 0.34 0.74 0.88 (0.78-0.93) 

DAS12 1.76 (1.41) 0.59 0.72 0.94 (0.89-0.97) 

DAS13 1.12 (0.98) 0.48 0.73 0.98 (0.96-0.99) 

DAS14 1.43 (0.80) 0.59 0.73 0.91 (0.83-0.95) 

DAS15 0.70 (0.85) 0.22 0.74 0.84 (0.71-0.91) 

DAS16 1.96 (1.30) 0.58 0.73 0.90 (0.82-0.94) 

DAS17 2.64 (1.23) 0.54 0.73 0.94 (0.89-0.97) 

DAS18 2.08 (1.36) 0.63 0.72 0.83 (0.70-0.91) 

DAS19 1.44 (1.09) 0.69 0.73 0.95 (0.92-0.97) 

DAS20 2.07 (0.98) 0.51 0.73 0.88 (0.79-0.94) 

DAS21 1.01 (1.09) 0.57 0.73 0.92 (0.85-0.96) 

DAS22 1.11 (0.89) 0.43 0.73 0.75 (0.57-0.86) 

DAS23 1.72 (1.23) 0.56 0.73 0.95 (0.91-0.97) 

DAS24 1.25 (1.07) 0.55 0.73 0.80 (0.66-0.89) 

Total 39.80 (14.26) 1.00 0.89 0.96 (0.93-0.98) 

 

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6 

Khani A, Babaee T, Khaghani A, Nakhaee M, Fatahi Z, Moss T. Reliability and validity testing of the Persian version of the Derriford Appearance Scale 24 in a 
sample of individuals with craniofacial irregularity and amputation. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v6i1.41454 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE PERSIAN VERSION OF THE DERRIFORD APPEARANCE SCALE 24 
Khani et al., 2023 

However, Moss et al. concluded that by removing 5 items of 

the Taiwanese version of DAS24, the Cronbach’s alpha of 

the instrument would increase to 0.97 and therefore, the 

Taiwanese version includes only 19 items.21 The present 

study also revealed that the P-DAS24 demonstrated 

excellent test-retest reliability (r= 0.96) which was similar to 

the findings of the original English and the Taiwanese 

versions (r= 0.82, 0.88, respectively).19,21 

As to assess the known-groups construct validity, we 

compared the means and total scores of the P-DAS24 in 

individuals with regard to their gender and level of 

involvement. In terms of gender, the total score of P-DAS24 

did not show a significant difference between men and 

women. This is in contrast to the notable difference between 

men and women in the Original English19 and 

Brazilian/Portuguese versions22 This might be due to the 

fact that Iranian women are supposed to wear modesty 

dressings known as ‘Hijab’ which prevents them from 

exposing their body in the society. However, in items DAS2 

‘Distressed at reflection’ and DAS18 ‘Distressed by clothing 

Table 3: Known-groups validity of the Persian-DAS24. 
 

 
Items  

Sex Level of amputation Normal and Disfigured individuals 

Male 
(n=201) 

Female 
(n=50) 

Maxillof
acial  

(n= 30) 

Upper Limb 
Amputation 

(n= 25) 

Transfemoral 
(n= 45) 

Knee 
(n= 11) 

Transtibial  
(n= 111) 

Partial foot  
amputation 
and ankle 

disarticulation 
(n= 29) 

Normal Individuals 
(n= 101) 

Disfigured 
Individuals               
(n= 251) 

DAS1  123.63 133.36 182.17 166.78 113.99 113.95 111.21 112.57 208.75 163.52 

p 0.36 0.00 0.00 

DAS2 119.25 149.71 203.73 169.54 105.17 104.64 112.94 93.71 160.08 181.67 

p 0.00 0.00 0.05 

DAS3 122.64 132.26 199.92 142.35 123.00 149.36 107.04 95.67 179.84 173.06 

p 0.37 0.00 0.55 

DAS4 123.69 133.11 186.57 137.12 126.17 80.18 114.64 114.38 105.07 205.24 

p 0.38 0.00 0.00 

DAS5 127.72 113.60 196.70 147.26 131.05 139.32 105.56 95.74 188.84 170.17 

p 0.20 0.00 0.10 

DAS6 127.16 110.56 176.12 108.43 127.41 146.32 122.77 77.10 149.14 185.53 

p 0.14 0.00 0.00 

DAS7 126.97 116.54 177.87 124.44 115.94 130.73 119.27 108.71 156.51 183.87 

p 0.35 0.00 0.01 

DAS8 125.27 108.38 129.65 125.61 129.52 110.23 118.32 121.79 151.72 181.02 

p 0.12 0.89 0.00 

DAS9 122.62 137.61 194.78 161.92 123.93 126.59 106.61 101.09 176.20 176.62 

p 0.17 0.00 0.97 

DAS10 121.94 127.48 148.15 114.52 117.15 182.23 122.68 94.17 188.64 167.35 

p 0.61 0.0 0.06 

DAS11 121.97 127.46 164.43 138.37 119.35 94.50 114.84 119.36 168.74 175.44 

p 0.52 0.00 0.44 

DAS12 121.30 135.19 188.47 136.70 123.66 91.55 113.70 104.74 158.18 181.85 

p 0.21 0.00 0.04 

DAS13 128.02 114.89 179.62 133.16 117.08 123.77 122.99 90.57 173.00 177.91 

p 0.21 0.00 0.64 

DAS14  124.32 127.84 187.73 137.78 127.70 120.77 111.51 101.98 187.81 171.23 

p 0.69 0.00 0.08 

DAS15 125.43 115.32 140.02 119.87 128.28 118.23 123.14 109.66 178.33 172.25 

p 0.33 0.60 0.57 

DAS16 123.36 134.51 191.38 140.52 119.60 80.73 118.76 100.67 142.78 189.24 

p 0.32 0.00 0.00 

DAS17 124.73 128.74 185.92 147.06 123.48 103.73 113.18 107.28 129.29 194.61 

p 0.71 0.00 0.00 

DAS18 119.11 149.68 178.53 132.78 125.81 120.45 118.53 92.24 163.99 180.85 

p 0.00 0.00 0.14 

DAS19 124.73 128.73 203.63 142.58 116.37 119.68 111.08 105.84 164.72 180.49 

p 0.71 0.00 0.16 

DAS20 124.81 128.41 177.25 138.36 140.67 71.59 114.32 104.91 143.61 189.74 

p 0.74 0.00 0.00 

DAS21 128.28 105.80 181.62 121.89 127.32 104.86 114.14 110.29 165.43 178.16 

p 0.03 0.00 0.25 

DAS22 124.47 127.23 168.67 148.73 108.73 137.18 112.42 133.26 199.63 166.45 

p 0.78 0.00 0.00 

DAS23 124.16 131.13 197.32 153.92 120.06 137.27 102.69 122.31 180.20 175.01 

p 0.53 0.00 0.65 

DAS24 130.41 104.82 185.02 144.46 122.08 146.41 105.93 124.19 169.42 179.35 

p 0.01 0.00 0.35 

Total 124.57 129.40 123.48 153.06 124.00 118.41 106.18 83.66 156.36 184.61 

p 0.67 0.00 0.01 

 

https://doi.org/10.33137/cpoj.v6i1.41454


 

7 

Khani A, Babaee T, Khaghani A, Nakhaee M, Fatahi Z, Moss T. Reliability and validity testing of the Persian version of the Derriford Appearance Scale 24 in a 
sample of individuals with craniofacial irregularity and amputation. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v6i1.41454 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE PERSIAN VERSION OF THE DERRIFORD APPEARANCE SCALE 24 
Khani et al., 2023 

limitations’, in which certain amounts of exposure were 

required and women are stereotypically expected to 

maintain their feminine physique,29 women were reported to 

experience significantly higher distress than men. This was 

in line with the findings of a recent study revealing that body 

image perception was significantly different between men 

and women with lower limb amputation30 and women were 

more affected than men in relation to body image anxiety.31 

However, significantly higher scores of men for item DAS24 

‘Avoid restaurants’ revealed the higher distress experienced 

by them in a social occasion.  

Women, on the other hand, had a significantly lower score 

for this item, which can be explained by the cultural 

difference between women’s dressing in an Islamic 

community to that of a western community and how easier 

for Muslim women is to conceal their body parts.  One 

limitation of this study was the heterogeneity of the included 

participants regarding their cause of irregularity. The DAS-

24 has been developed to assess distress and dysfunction 

to problems of appearance in individuals with any types of 

visible irregularity. Therefore, this questionnaire has been 

widely used in different sample of participants with minimal 

to severe forms of disfigurement. In other translated 

versions of this questionnaire, the study samples composed 

of heterogeneous individuals with visible irregularities 

including burn, cleft lip/palate, hemangioma, 

neurofibromatosis, oral cancer, and HIV/AIDS.21,22 That’s 

why we included individuals with different cause of 

disfigurement.  

Facially or physically disfigured individuals encounter 

various psychosocial problems depending on the site and 

level of their amputation or disfigurement.6 Our findings 

indicate that the total score of individuals with different 

disfigurements were significantly different in P-DAS24. 

Similarly, Moss et al. reported a significant effect of the body 

site affected on the scoring of participants in their study 

(P<0.0001).19 Depression and anxiety seen in upper limb 

amputees are significantly higher than that of lower limb 

amputees.31 Among lower-limb amputees, the individuals 

with transtibial amputation can conceal their difference/ 

irregularity more easily than transfemoral amputees and 

hence experience less scrutiny in the society.5,32  

Prosthetic reconstruction has proved to improve the self-

image and self-esteem of those missing a body part.33 This 

might be due to the fact that by means of various prosthetic 

designs and the advancement in their aesthetic 

appearance, disfigured individuals are able to conceal their 

difference more easily and thus avoid the stigma and 

distress they encounter in social occasions. The DAS24 has 

previously been used to determine changes in the distress 

level of patients undergoing rhinoplasty and the results 

showed a significant decrease in their stress level after the 

surgery.34 However, since it takes a considerable amount of 

time for amputees to adapt themselves to their prostheses 

and the cross-sectional nature of our study design, we were 

not able to compare the self-image perception and body 

image anxiety of amputees before and after the prosthetic 

reconstruction. We recommend future studies focus on the 

impact of prosthetic reconstruction on self-image 

disturbance of individuals with maxillofacial irregularity and 

limb loss. 

In terms of discriminant validity, our findings revealed that 

the P-DAS24 is able to discriminate between the normal 

population and the group with disfigurement (P=0.01). 

Visible dissimilarity exposes individuals to social isolation 

that might occur as a result of the timidity, anxiety and 

distress they experience regularly.21 In a sample of 

Taiwanese individuals, it was shown that the visibly different 

group scored significantly higher scores for DAS24 

compared to the non-visibly different group.21 Also, the 

mean scores of the general population and the clinical 

population participating in the study by Moss et al. were 

significantly different (P<0.0005).19 Although participants in 

our study were all using prosthesis as to compensate for the 

functional and cosmetic aspect of their body, the results 

showed significantly higher incidence of distress and 

anxiety in these individuals. This shows the sensitivity of this 

construct to underlying conditions leading to visible 

difference and its impact on social interaction of people with 

disfigurements. 

CONCLUSION 

This study provided an effective translation and culturally 

adapted version of the DAS24 to assess the distress and 

self-image disturbance of disfigured individuals. This 

instrument can be used in clinical practice and researches 

to assess the outcomes of prosthetic reconstructions in 

individuals with disfigurement. 

ACKNOWLEDGEMENTS 

The authors would like to thank the participants for taking part in 

this study. 

DECLARATION OF CONFLICTING INTERESTS 

The authors declare that there is no conflict of interest. 

AUTHORS CONTRIBUTION 

• Alireza Khani and Taher Babaee: writing (original draft 

preparation, review and editing), design and conceptualization.  

• Alireza Khaghani, Masoomeh Nakhaee, Timothy Peter 

Moss: design and conceptualization, writing (review and 

editing).  

All authors have read and agreed to the published version of 

the manuscript. 

 

SOURCES OF SUPPORT 

This work was supported by the research ethics committee of 

Kerman University of Medical Sciences. 

https://doi.org/10.33137/cpoj.v6i1.41454


 

8 

Khani A, Babaee T, Khaghani A, Nakhaee M, Fatahi Z, Moss T. Reliability and validity testing of the Persian version of the Derriford Appearance Scale 24 in a 
sample of individuals with craniofacial irregularity and amputation. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v6i1.41454 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE PERSIAN VERSION OF THE DERRIFORD APPEARANCE SCALE 24 
Khani et al., 2023 

ETHICAL APPROVAL 

The study protocol was approved by the research ethics committee 

of Kerman University of Medical Sciences (Ref: # 

IR.KMU.REC.1399.413, date: 27/07/1399). 

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9 

Khani A, Babaee T, Khaghani A, Nakhaee M, Fatahi Z, Moss T. Reliability and validity testing of the Persian version of the Derriford Appearance Scale 24 in a 
sample of individuals with craniofacial irregularity and amputation. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.3. 
https://doi.org/10.33137/cpoj.v6i1.41454 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X THE PERSIAN VERSION OF THE DERRIFORD APPEARANCE SCALE 24 
Khani et al., 2023 

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