Cross Cultural adaptation into Brazilian Portuguese language of Derriford Appearance Scale 24 (DAS-24) for people living with HIV/AIDS

  • Marcos Alberto Martins Laboratório de Delineamento de Estudos e Escrita Científica. Centro Universitário Saúde ABC, Santo André, SP, /Serviço de Cirurgia Plástica do Hospital Samaritano de São Paulo, SP
  • Angela Nogueira Neves Escola de Educação Física do Exército
  • Timothy Moss University of the West of England
  • Walter Henrique Martins Professor Assistente do Centro Universitário Saúde ABC, Santo André, SP
  • Gerson Vilhena Pereira Professor Titular do Centro Universitário de Saúde ABC
  • Karina Viviani de Oliveira Pessôa Programa Municipal de IST/AIDS e Hepatites Virais de São Bernardo do Campo, São Paulo
  • Mariliza Henrique da Silva Programa Estadual de IST/AIDS de São Paulo
  • Luiz Carlos de Abreu Laboratório de Delineamento de Estudos e Escrita Científica. Centro Universitário Saúde ABC, Santo André, SP
Keywords: Body Image, Appearance, HIV/AIDS, Psychometry


Introduction: Body image can be defined as the representation of beliefs, emotions and perceptions about the body itself, manifested in behaviors directed to the body. When the body changes because of a disease and does not seem healthy, the self-concept may be severely challenged. People living with HIV/AIDS (PLHA) are particularly vulnerable to the distress and psychosocial impact of appearance, but in Brazil the assessment of those body image changes was subjective because there was not an available scale in Brazilian Portuguese to assess body image changes in clinical practice or research. Objective: To carry out the cross-cultural adaptation to the Brazilian Portuguese of the Derriford Appearance Scale 24 (DAS-24), with the verification of the linguistic, semantic, conceptual and cultural equivalence of the people living with HIV/AIDS in Brazil. Methods: We followed the five stages of culturally sensitive translation: direct translations, synthesis of translations, back-translations, expert committee meeting and pre-tests. The process of cultural adaptation was presented in a descriptive and analytical way, following patterns of methodological studies. The minimum, maximum and median values of the responses of each item were calculated from the pool of data from the third pretest group of 50 participants. The median of the item scores, the correlation on each item with the total score and the internal reliability, were calculated using the Cronbach alpha test. Results: The analysis of the responses of the last pre-test group indicated that attention must be given to items
A, H, T and V in a future psychometric study. The present study is not enough for this scale to be used in clinical practice. To ensure that the culturally adapted instrument generates valid and reliable data, a subsequent study investigating its psychometric properties should be conducted. Conclusion: The cross-cultural adaptation of the Derriford Appearance Scale 24 (DAS-24) in its components of linguistic, semantic, conceptual and cultural equivalence to Brazilian Portuguese for the population of people living with HIV/AIDS was fully carried out. Despite this achievement, it is emphasized that the use of the Brazilian version
of DAS-24 in research and clinical routine is advised only after a psychometric study with this instrument.


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1. Cash TF. Cognitive-Behavioral perspectives on body image. In: Cash TF, Smolak L. Body image: a handbook of science, practice, and prevention. New York: Guilford Press, 2011; p. 39-47.

2. Cash T. Cognitive-Behavioral perspectives on body image. In: Cash T. Encyclopedia of body image and human appearance. V.1. Elsevier, 2012; p.334-42.

3. Cash TF. The Body Image workbook: an 8-step program for learning to like your looks. New York: The Guilford Press, 2000.

4. Mauss M. As técnicas corporais. In: Mauss M. Sociologia e antropologia. São Paulo: EPU; EDUSP, 1974.

5. Puhl RM, Peterson JL. Physcial appearance and stigma. In: Cash TF. Encyclopedia of body image and human appearance. Academic Press, 2012; p.588-94.

6. Katre C, Johnson IA, Humphris GM, Lowe D, Rogers SN. Assessment of problems with appearance, following surgery for oral and oro-pharyngeal cancer using the University of Washington appearance domain and the Derriford appearance scale. Oral Oncol. 2008;44(10):927-34. DOI:

7. Moreira H, Canavarro MC. The association between self-consciousness about appearance and psychological adjustment among newly diagnosed breast cancer patients and survivors: the moderating role of appearance investment. Body Image. 2012;9(2):209-15. DOI:

8. Moreira H, Canavarro MC. A longitudinal study about the body image and psychosocial adjustment of breast cancer patients during the course of the disease. Eur J Oncol Nurs. 2010;14(4):263-70. DOI:

9. Merz EL, Kwakkenbos L, Carrier ME, Gholizadeh S, Mills SD, Fox RS, et al. Factor structure and convergent validity of the Derriford Appearance Scale-24 using standard scoring versus treating ‘not applicable’ responses as missing data: a Scleroderma Patient-centered Intervention Network (SPIN) cohort study. BMJ Open. 2018;8(3):e018641. DOI:

10. Moss TP, Rosser BA. The moderated relationship of appearance valence on appearance self consciousness: development and testing of new measures of appearance schema components. PloS One. 2012;7(11):e50605. DOI:

11. Lupton D. Medicine as culture: Illness, disease and the body. Los Angeles: Sage, 2012. 12. Tavares MCGF. Imagem corporal: conceito e desenvolvimento. Barueri: Manole, 2003.

13. Schilder PA. Imagem do corpo: as energias construtivas da Psiquê. São Paulo: Martins Fontes, 1980.

14. Williamson H. The psychosocial impact of being a young person with an unusual appearance. J Aesthetic Nurs. 2014;3(4):186-8. DOI:

15. Harcourt D, Rumsey N. Body Image and Biomedical Interventions for Disfiguring Conditions. In: Cash TF, Smolak L. Body Image: a handbook of science, practice and prevention. 2 ed. New York: Guilford Press, 2011; p.404-14.

16. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de DST, Aids e Hepatites Virais. Manual de tratamento da lipoatrofia facial: recomendações para o preenchimento facial com polimetilmetacrilato em portadores de HIV/AIDS. Brasília: Ministério da Saúde, 2009.

17. Hoffmann C, Rockstroh JK. HIV 2015/2016. Medizin Fokus Verlag, 2015. [cited 2019 Feb 27] Available from:

18. Alexias G, Savvakis M, Stratopoulou?. Embodiment and biographical disruption in people living with HIV/AIDS (PLWHA). AIDS Care. 2016;28(5):585-90. DOI:

19. Earnshaw VA, Bogart LM, Dovidio JF, Williams DR. Stigma and racial/ethnic HIV disparities: moving toward resilience. Am Psychol. 2013;68(4):225-36. DOI:

20. Kumar S, Samaras K. The Impact of Weight Gain During HIV Treatment on Risk of Pre-diabetes, Diabetes Mellitus, Cardiovascular Disease, and Mortality. Front Endocrinol. 2018; 9:705. DOI:

21. Brener L, Callander D, Slavin S, Wit J. Experiences of HIV stigma: the role of visible symptoms, HIV centrality and community attachment for people living with HIV. AIDS Care. 2013;25(9):1166-73. DOI:

22. Kalichman SC, Simbayi LC, Cloete A, Mthembu PP, Mkhonta RN, Ginindza T. Measuring AIDS stigmas in people living with HIV/AIDS: the Internalized AIDS-Related Stigma Scale. AIDS Care. 2009;21(1):87-93. DOI:

23. Simbayi LC, Kalichman S, Strebel A, Cloete A, Henda N, Mqeketo A. Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Soc Sci Med. 2007;64(9):1823-31. DOI:

24. Leclercq P, Goujard C, Duracinsky M, Allaert F, L’henaff M, Hellet M, et al. High prevalence and impact on the quality of life of facial lipoatrophy and other abnormalities in fat tissue distribution in HIV infected patients treated with antiretroviral therapy. AIDS Res Hum Retroviruses. 2013;29(5):761-8. DOI:

25. Cofrancesco J Jr, Brown T, Martins CR. Management options for facial lipoatrophy. AIDS Read. 2004;14(12):639-40.

26. Tate H, George R. The effect of weight loss on body image in HIV-positive gay men. AIDS Care. 2001;13(2):163-9. DOI:

27. Reynolds N, Diamantopoulos A, Schiegelmilch B. Pretesting in questionnaire desing: a review of the literature and suggestions for future research. Int J Market Res. 1993;35(2): 171-82. DOI:

28. Abel G, Thompson L. “I don’t want to look like an AIDS victim”: A New Zealand case study of facial lipoatrophy. Health Soc Care Community. 2018;26(1):41-7. DOI:

29. Williamson H, Wallace M. When treatment affects appearance. In: Runsey N, Harcour D. The Oxford handbook of the psychology of appearance. Reino Unido: Oxford University Press, 2012; p.414-38.

30. Rzeszutek M, Gruszczy?ska E. Posttraumatic growth among people living with HIV: a systematic review. J Psychosom Res. 2018;114:81-91. DOI:

31. Carr T, Moss T, Harris D. The DAS24: A short form of the Derriford Appearance Scale DAS59 to measure individual responses to living with problems of appearance. Br J Health Psychol. 2005;10(Pt 2):285-98. DOI:

32. Campana ANNB, Tavares MCGCF. Avaliação da imagem corporal: Instrumentos e diretrizes para a pesquisa. São Paulo: Phorte, 2009.

33. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Recommendations for the Cross-Cultural adaptation of Healthy Status Measures. American Academy of Orthopaedic Surgeons and Institute for Work & Health, 1998.

34. Malhotra NK. Pesquisa de marketing: uma orientação aplicada. Porto Alegre: Bookman, 2008.

35. Reynolds NR, Neidig JL, Wu AW, Gifford AL, Holmes WC. Balancing disfigurement and fear of disease progression: patient perceptions of HIV body fat redistribution. Aids Care. 2006;18(7):663-673. DOI:

36. Zangirolami-Raimundo J, Echeimberg JO, Leone C. Research methodology topics: Cross-sectional studies. J Hum Growth Dev. 2018;28(3):356-360. DOI:

37. DeVellis RF. Scale development: theory and applications. 2 ed. Thousand Oaks: Sage Publications, 2003.

38. Clark LA, Watson D. Constructing validity: basic issues in objective scale development. Psychol Assessment. 1995;7(3):309-19. DOI:

39. Hair JR, Anderson RE, Tatham RL, Black WC. Análise Multivariada de Dados. 6.ed. Porto Alegre: Bookman, 2009.

40. Nunnally JC, Bernstein IH. Psychometric theory. 3rd ed. New York: McGraw-Hill, 1994.

41. Zeman AZ, Grayling AC, Cowey A. Contemporary theories of consciousness. J Neurol Neurosurg Psychiatry. 1997;62(6):549-552. DOI:

42. Moreira H, Canavarro MC. The Portuguese version of the Derriford Appearance Scale – 24. Department of Psychology, Faculty of Psychology and Education Sciences, Coimbra, Portugal: 2007.

43. VandenBos GR. APA Dictionary of psychology. Washington: American Psychological Association, 2007.

44. Ferreira L, Neves AN, Campana MB, Tavares MCGCF. Guia da AAOS/IWH: sugestões para adaptação transcultural de escalas. Aval Psicol. 2014;13(3):457-61.

45. Moss TP, Lawson V, Liu CY. The Taiwanese Derriford Appearance Scale: The translation and validation of a scale to measure individual responses to living with problems of appearance. Psych J. 2015;4(3):138-45. DOI:

46. Sousa P, Gaspar P, Fonseca H, Hendricks C, Murdaugh C. Health promoting behaviors in adolescence: validation of the Portuguese version of the Adolescent Lifestyle Profile. J Pediatr (Rio J). 2015;91(4):358-65. DOI:

47. Khalaila R. Translation of questionnaires into arabic in cross-cultural research: techniques and equivalence issues. J Transcult Nurs. 2013;24(4):363-70. DOI: