Translation and Validation of the Nepalese Version of Derriford Appearance Scale (DAS59)

doi:10.4236/mps.2013.32010

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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.

Email: *[email protected]

Received November 23rd, 2012; revised December 26th, 2012; accepted January 2nd, 2013

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)

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)

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.

REFERENCES

[1] M. T. Hilhorst, “Phy sical Beauty: Only Skin Deep?” Me-

dicine, Health Care and Philosophy, Vol. 5, No. 1, 2002,

pp. 11-21. doi:10.1023/A:1014217922801

[2] K. Dion, E. Berscheid and E. Walster, “What Is Beautiful

Is Good,” Journal of Personality and Social Psychology,

Vol. 24, No. 3, 1972, pp. 285-290. doi:10.1037/h0033731

[3] K. K. Dion, “Physical Attractiveness and Evaluation of

Children’s Transgressions,” Journal of Personality and

Social Psychology, Vol. 24, No. 2, 1972, pp. 207-213.

doi:10.1037/h0033372

[4] E. Walster, V. Aronson, D. Abrahams and L. Rottman,

“Importance of Physical Attractiveness in Dating Behav-

ior,” Journal of Personality and Social Psychology, Vol.

4, No. 5, 1966, pp. 508-516. doi:10.1037/h0021188

[5] W. C. Shaw, “Factors Influencing the Desire for Ortho-

dontic Treatment,” European Journal of Orthodontics,

Vol. 3, No. 3, 1981, pp. 151-162.

[6] W. C. Shaw, G. Rees, M. Dawe and C. R. Charles, “The

Influence of Dentofacial Appearance on the Social At-

tractiveness of Young Adults,” American Journal of Or-

thodontics, Vol. 87, No. 1, 1985, pp. 21-26.

doi:10.1016/0002-9416(85)90170-8

[7] S. J. Cunningham, “The Psychology of Facial Appear-

ance,” Dental Update, Vol. 26, No. 10, 1999, pp. 438-

444.

[8] C. Philips, M. E. Bennett and H. L. Broder, “Dentofacial

Disharmony: Psychological Status of Patients Seeking a

Treatment Consultation,” The Angle Orthodontist, Vol.

68, No. 6, 1998, pp. 547-556.

[9] H. L. Broder, C. Phillips and S. Kaminetzky, “Issues in

Decision Making: Should I Have Orthognathic Surgery?”

Seminars in Orthodontics, Vol. 6, No. 4, 2000, pp. 249-

258. doi:10.1053/sodo.2000.19073

[10] F. C. Macgregor, “Social and Psychological Implications

of Dentofacial Disfigurement,” The Angle Orthodontist,

Vol. 40, No. 3, 1970, pp. 231-233.

[11] F. C. Macgregor, “Facial Disfigurement: Problems and

Management of Social Interaction and Implications for

Mental Health,” Aesthetic Plastic Surgery, Vol. 14, No. 1,

1990, pp. 249-257. doi:10.1007/BF01578358

[12] H. W. Neale, D. A. Billmire and J. P. Carey, “Recon-

struction Following Head and Neck Burns,” Clinical

Plastic Surgery, Vol. 13, No. 1, 1986, pp. 119-136.

[13] E. E. Williams and T. A. Griffiths, “Psychological Con-

sequences of Burn Injury,” Burns, Vol. 17, No. 6, 1991,

pp. 478-480.

[14] E. Stice and H. E. Shaw, “Role of Body Dissatisfaction in

the Onset and Maintenance of Eating Pathology: A Syn-

thesis of Research Findings,” Journal of Psychosomatic

Research, Vol. 53, No. 5, 2002, pp. 985-993.

doi:10.1016/S0022-3999(02)00488-9

[15] B. Verplanken and R. Velsivik, “Habitual Negative Body

Image Thinking as Psychological Risk Factor in Adoles-

cents,” Body Image, Vol. 5, No. 2, 2008, pp. 133-140.

doi:10.1016/j.bodyim.2007.11.001

[16] T. Carr, D. Harris and C. James, “The Derriford Appear-

ance Scale (DAS-59): A New Scale to Measure Individ-

ual Responses to Living with Problems of Appearance,”

British Journal of Health Psychology, Vol. 5, No. 2, 2000,

pp. 201-215. doi:10.1348/135910700168865

[17] T. F. Cash and A. S. Labarage, “Development of Ap-

pearance Schemas Inventory: A New Cognitive Body-

Image Assessment,” Cognitive Therapy and Research,

Vol. 20, No. 1, 1996, pp. 37-50.

doi:10.1007/BF02229242

[18] J. C. Rosen, D. Srebnik, E. Saltzburg and S. Wendt, “De-

velopment of a Body Image Avoidance Questionnaire,”

Psychological Assessment: Journal of Consulting and

Clinical Psychology, Vol. 3, No. 3, 1991, pp. 32-37.

[19] J. Rosen, J. Reiter and P. Osoran, “Cognitive-Behavioral

Body Image Therapy for Body Dysmorphic Disorder,”

Journal of Consulting and Clinical Psychology, Vol. 63,

No. 2, 1995, pp. 263-269.

doi:10.1037/0022-006X.63.2.263

[20] D. L. Harris and A. T. Carr, “The Derriford Appearance

Scale (DAS59): A New Psychometric Scale for the

Evaluation of Patients with Disfigurements and Aesthetic

Problems of Appearance,” British Journal of Plastic Sur-

gery, Vol. 54, No. 3, 2001, pp. 216-222.

doi:10.1054/bjps.2001.3559

[21] T. P. Moss, P. White, S. Newman and H. James, “Factor

Analysis of the DAS24: Conceptual and Statistical Is-

sues,” Presented at Appearance Matters 4 Conference,

Bristol, 2010.

[22] T. Carr, T. Moss and D. Harris, “The DAS24: A Short

Form of the Derriford Appearance Scale (DAS59) to

Measure Individual Responses to Living with Problems

of Appearance,” British Journal of Health Psychology,

Vol. 10, No. 2, 2005, pp. 285-298.

doi:10.1348/135910705X27613

[23] N. Keiko, H. Kazuhiro, N. Nobuaki, N. Reiko, I. Katsun-

ori, I. Nobuak, T. P. Moss and D. L. Harris, “Develop-

ment of the Japanese Version of Derriford Appearance

Scale DAS59: A QOL Index for the People Who Have

Problems of Appearance,” Journal of Japan Society of

Plastic and Reconstructive Surgery, Vol. 28, No. 7, 2008,

pp. 440-448.

[24] T. B. Won, K. T. Park, S. J. Moon, I. J. Moon, J. H. Wee,

Translation and Validation of the Nepalese Version of Derriford Appearance Scale (DAS59)

T. Moss and H. R. Jin, “The Effect of Septorhinoplasty

on Quality of Life and Nasal Function in Asians,” Annals

of Plastic Surgery, 2012.

doi:10.1097/SAP.0b013e3182414641

[25] D. Harris, T. P. Moss and T. Carr, “Manual for the Derri-

ford Appearance Scale 59 (DAS59),” Musketeer Press,

Bradford on Avon, 2004.

[26] N. R. Koirala, S. K. Regmi, V. D. Sharma, A. Khalid and

M. K. Nepal, “Sensitivity and Validity of the General

Health Questionnaire-12 in a Rural Community Settings

in Nepal,” Nepalese Journal of Psychiatry, Vol. 1, No. 1,

1999, pp. 34-40.

[27] B. A. Kohrt, R. D. Kunz, N. R. Koirala, V. D. Sharma

and M. K. Nepal, “Validation of a Nepali Version of the

Beck Depression Inventory,” Nepalese Journal of Psy-

chiatry, Vol. 2, No. 4, 2002, pp. 123-130.

[28] B. A. Kohrt, R. D. Kunz, N. R. Koirala, V. D. Sharma

and M. K. Nepal, “Validation of a Nepali Version of the

Beck Anxiety Inventory,” Nepalese Journal of Psychiatry,

Vol. 25, No. 1, 2003, pp. 1-4.

[29] K. Peker, O. Uysal and G. Bermek, “Cross Cultural Ad-

aptation and Preliminary Validation of the Turkish Ver-

sion of the Early Childhood Oral Health Impact Scale

among 5 - 6-Year-Old Children,” Health and Quality of

Life Outcomes, Vol. 9, 2011, p. 118.

doi:10.1186/1477-7525-9-118