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Year : 2019  |  Volume : 15  |  Issue : 3  |  Page : 653-658

Reliability and psychometric validity of Hindi version of Depression, Anxiety and Stress Scale-21 (DASS-21) for Hindi speaking Head Neck Cancer and Oral Potentially Malignant Disorders Patients

1 Department of Oral and Maxillofacial Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Geriatric Mental Health, King George's Medical University, Lucknow, Uttar Pradesh, India
3 Department of Surgical Oncology, King George's Medical University, Lucknow, Uttar Pradesh, India
4 Department of Otolaryngology, Addenbrooke's Hospital, Cambridge University Teaching Hospitals, NHS Foundation Trust, Cambridge, UK

Date of Web Publication29-May-2019

Correspondence Address:
Prof. Divya Mehrotra
Department of Oral and Maxillofacial Surgery, King George's Medical University, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_281_17

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 > Abstract 

Background and Objectives: The aim of the present study was to carefully translate and psychometrically validate the depression, anxiety, and stress scale-21 (DASS-21) in Hindi language for Hindi-speaking head and neck cancer (HNC) and oral potentially malignant disorder (OPMD) patients.
Materials and Methods: One hundred and sixty-seven HNC and OPMD patients were recruited for this study comprising of 111 oral cancer and 56 OPMD patients. According to internationally accepted guidelines, forward and backward translation procedures were performed, to develop a culturally acceptable version of DASS-21. Validated Hindi version of hospital anxiety and depression scale (HADS) questionnaire was used to compare the scores. Internal consistency for construct validity of the DASS-21 was assessed. Related data and the patients' demographics details were recorded. Factor analysis using varimax rotation was also carried out.
Results: The Cronbach's alpha values were 0.998, 0.990, and 0.994, respectively, for depression, anxiety, and stress domains, which was comparable to other studies and indicated a strong internal consistency and good construct validity. Factor and varimax analysis revealed items to be well suited to their respective domains. A statistically significant strong correlation was reflected with HADS Hindi questionnaire; Spearman's rank correlation values observed were 0.80 and 0.83 for depression and anxiety, respectively.
Interpretation and Conclusions: Hindi version of the DASS-21 questionnaire appears to be culturally appropriate, reliable, and psychometrically valid tool for evaluation of the psychological burden (depression, anxiety, and stress) in Hindi-speaking HNC and OPMD patients.

Keywords: Anxiety, depression, anxiety and stress scale-21, depression, oral cancer, psychometric validity

How to cite this article:
Kumar K, Kumar S, Mehrotra D, Tiwari SC, Kumar V, Dwivedi RC. Reliability and psychometric validity of Hindi version of Depression, Anxiety and Stress Scale-21 (DASS-21) for Hindi speaking Head Neck Cancer and Oral Potentially Malignant Disorders Patients. J Can Res Ther 2019;15:653-8

How to cite this URL:
Kumar K, Kumar S, Mehrotra D, Tiwari SC, Kumar V, Dwivedi RC. Reliability and psychometric validity of Hindi version of Depression, Anxiety and Stress Scale-21 (DASS-21) for Hindi speaking Head Neck Cancer and Oral Potentially Malignant Disorders Patients. J Can Res Ther [serial online] 2019 [cited 2021 Dec 4];15:653-8. Available from: https://www.cancerjournal.net/text.asp?2019/15/3/653/244448

 > Introduction Top

A number of questionnaires are available that are used to investigate psychological issues in terms of depression, anxiety, and stress, but not a single tool is available that has evaluated depression, anxiety, and stress altogether. Depression, anxiety, and stress scale (DASS-21) is a short version tool which evaluates depression, anxiety, and stress at one time. To the best of our knowledge, it has not been used for Hindi-speaking head and neck cancer (HNC) patients till date. Therefore, to overcome this, authors have investigated its psychometric properties and validated Hindi version of DASS-21 for use in Hindi-speaking HNC patients.

 > Materials and Methods Top


One hundred and eleven patients of recently diagnosed oral cancer and fifty-six oral potentially malignant disorder (OPMD) patients attending the Department of Oral and Maxillofacial Surgery of a reputed college were recruited in the study after obtaining informed consent. Patients with a history of any previous treatment or currently undergoing treatment for any cancer or known psychological problems were excluded from the study at the very outset.


This hospital-based study was approved by the Institutional Ethics Committee. Data were collected for over a period of 2 years from January 2013 to January 2015 by specially trained dental surgeon (SK) and a psychologist (KK), to minimize the systematic error. General Health Questionnaire (GHQ-12) was used to screen and rule out any psychiatric ailments before recruiting patients for this study. Patients enrolled in this study were interviewed by a trained psychologist (KK), and their psychological functioning was assessed using questionnaire DASS-21. Patients observed with severe anxiety, depression, and stress were referred to the Department of Psychiatry for counseling.

Demographic status

Level of education, occupation, income, marital status, religion, domiciliary status, date of birth, age, gender, and other relevant clinicodemographic details of enrolled patients were recorded. Socioeconomic status was measured using Kuppuswamy's Socioeconomic Status Scale.[1]


General health questionnaire-12

The GHQ-12, a tool, to measure current mental health, was administered in all selected patients. It is a self-administered questionnaire which is composed to find out diagnosable psychiatric disorders in individuals.[2] GHQ-12 was used to focus on two major areas – the inability to implement normal functions and the probability of new and distressing experiences.

Depression, anxiety, and stress scale questionnaire

DASS-21 was used to measure negative emotional phases of depression, anxiety, and stress, which is a shorter version of the 42-item questionnaire.[3] It is a validated tool for evaluation of psychological burden and to assess the psychological state in wide range of diseases.

Depression component of this scale evaluates devaluation of life, inertia, self-depreciation, anhedonia, hopelessness, lack of interest/involvement, and dysphoria. There were seven questions evaluating depression. Score of 0–9, 10–13, 14–20, and 21–27 was considered as normal, mild, moderate, and severe, respectively. The score above 27 was considered as having extremely severe condition with depression.

Anxiety component of this scale evaluates situational anxiety, skeletal muscle effects, autonomic arousal, and subjective experience of anxious affect. There were seven questions evaluating anxiety. Score of 0–7, 8–9, 10–14, and 15–19 was considered as normal, mild, moderate, and severe, respectively. The score above 20 was considered having extremely severe condition with anxiety.

The stress component of this scale is sentient to levels of chronic nonspecific arousal. It evaluates difficulty in nervous arousal and relaxing, being easily irritable/overreactive, upset/agitated, and impatient. There were seven questions evaluating stress, and the score of 0–14, 15–18, 19–25, and 26–33 was considered as normal, mild, moderate, and severe. The score above 34 was considered having extremely severe condition with stress. As this was the short version, the total score of each component was multiplied by 2.[3]

The questionnaire was translated initially using seven-step procedure and was culturally adapted into Hindi language. The seven steps were preparation; forward translation; synthesis; back translation, expert committee review; pretesting; and validation [4] as shown in [Table 1]. After the translation, individuals were asked to mark the scale at the spot that best described their state over the past 2 weeks.
Table 1: The seven-step process of translation of questionnaire

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The questionnaire was obtained, and the semantic differences were identified. The questionnaire was handed over to a person who is familiar with Indian English, and thus, the final version was obtained.


The forward translation of the questionnaire was performed by two professional bilingual translators having knowledge of Hindi and English language. One of the translators had experience in translating medical questionnaires while other translator did not have any medical knowledge or clinical background. They worked independently and reported to translation coordinator for any queries and guidance.[5]


Two translations were compiled into one after resolving any discrepancies.

Back translation

The translated Hindi version was again translated to English language by two separate professional bilingual translators with no medical background. They were neither aware nor informed of concepts and were asked to stave off information bias and to detract emergent meanings of the translated questionnaire.[6],[7] The back translation was matched to the original English version, and thus, Hindi version was revised after resolving discrepancies. The procedure was repeated until all the discrepancies were resolved.

Expert committee review

Differences were verified by experts in a multidisciplinary team setting. The expert group comprised of health professionals, language professionals, clinical psychologists, and translators, and together, a prefinal version was produced.


Pilot testing was carried out on 20 patients with the prefinal version of the questionnaire. Any question or word which was difficult to understand, confusing, or upsetting as indicated by patients was reframed. Suggestions and improvements were made to the prefinal version.


After all these modifications, the final version was ready to be validated.

Statistical analysis

After taking all the demographic and treatment details from patients, the data were entered into an Excel worksheet. After extracting the data from the questionnaires into the worksheet, the analysis was performed using the commercially available Statistical Package for Social Sciences – 15 statistical software. After this, reliability and validity assessment of the data were done.


Internal consistency was measured using Cronbach's alpha coefficient and Spearman's rank correlation coefficient. An adequate internal consistency was indicated by the high Cronbach's alpha (>0.70) and Spearman's correlation coefficients (rho >0.60).


The depression and anxiety constructs were correlated with the related constructs of hospital anxiety and depression scale (HADS) using Spearman's rank correlation coefficient, which determines the construct validity. A value of P < 0.05 was considered as significant. Content or face validity was determined by evaluation of original content by common consensus process in a multidisciplinary team setting which consisted of experts and patients. In order to validate the four-factor structure of DASS-21, a confirmatory factor analysis was performed.

 > Results Top

Out of the 167 individuals (111 oral cancer and 56 OPMD patients) enrolled, most were males, belonged to Hindu religion, were married, and were from rural background. About 62% were semiskilled/skilled worker/clerical/shop owners/farmers and 47% belonged to upper lower strata [Table 2].
Table 2: Sociodemographic details of the patients enrolled in the study

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Cronbach's alpha value for depression, anxiety, and stress were >0.9 [Table 3] which corresponds to the ideal range of Cronbach's alpha which is >0.7.[8],[9]
Table 3: Reliability and validity of three constructs depression, anxiety, and stress

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Construct validity was evaluated by correlating overall grade scores of depression and anxiety of DASS-21 scale with depression and anxiety of HADS questionnaire using Spearman's rank correlation coefficient. The values of these coefficients were found to be 0.8 for depression and 0.83 for anxiety [Table 3].

Correlation >0.60 shows strong correlation, 0.40–0.60 moderate to substantial correlation, and <0.40 indicates weak correlation.

HADS does not have stress domain as compared to DASS. Analysis of correlation of total DASS score versus total HADS score showed significant correlation values.

Principal component analysis was carried out which specified four factors [Table 4]. Loading of >0.7 was considered as marked loading. Different items showed different factors such as Item 10 of depression (Hopelessness) “I felt that I had nothing to look forward to” was found to have a maximum loading of 0.8 in factor 2 whereas, item 21 (Devaluation of life) “I felt that life was meaningless,” item 17 (Self-deprecation) “I felt I wasn't worth much as a person”, item 3 (Anhedonia) “I couldn't seem to experience any positive feeling at all,” and item 16 (Lack of interest/involvement) “I was unable to become enthusiastic about anything” had a loading of 0.7 in factor 2 for item 21, 17, and 3 and 0.6 for item 16. Thus, item 10, 21, 17, 3, and 16 were found to saturate in factor 2 while item 13 (Dysphoria) “I felt down-hearted and blue” showed a loading of 0.6. In case of anxiety, only item 9 (Situational anxiety) “I was worried about situations in which I might panic and make a fool of myself” and item 15 (Subjective experience of anxious affect) “I felt I was close to panic” had a maximum loading of 0.79 and 0.67 in factor 1. Item 20 (Subjective experience of anxious affect) “I felt scared without any good reason” had a loading of 0.6 in factor 2. Under autonomic arousal, item no 4 “I experienced breathing difficulty (e.g., excessively rapid breathing and breathlessness in the absence of physical exertion)” demonstrated a loading of 0.6 in factor 3. Item 2 “I was aware of dryness of my mouth” and item 7 (under skeletal musculature effects) “I experienced trembling (e g., in the hands)” showed a loading of 0.6 in factor 4.
Table 4: Factor loadings (varimax rotation) of four factors

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In case of stress scale, only item 8 (under nervous arousal) “I felt that I was using a lot of nervous energy” and item 11 (under easily upset/agitated) “I found myself getting agitated” was observed to have a maximum loading of 0.8 and 0.7, respectively, in factor 1. Other items were found to have loading of >0.6. Factor loadings thus ranged from 0.22–0.81, 0.21–0.79, and 0.23–0.86 for depression, anxiety, and stress, respectively.

 > Discussion Top

Several questionnaires and self-report scales are available for assessment of depression, anxiety, and related constructs in Hindi language, but none was available for the patients with HNC. Though one such scale HADS was translated and validated in Hindi language, it measures only depression and anxiety domains and does not cover the stress domain. In order to overcome this drawback, DASS was selected.

The objective of the extant was to develop a Hindi version of the DASS-21 in HNC patients for the valid assessment and evaluation of the psychological burden in terms of depression, anxiety, and stress. The outcome in this study showed that DASS-21 Hindi version is reliable in internal consistency as it showed significant Cronbach's alpha values for the overall scale and in all 3 domains in DASS. The Cronbach's alpha values recorded in this study were 0.998, 0.990, and 0.994, respectively, for depression, anxiety, and stress domains. As Cronbach's alpha coefficient value becomes closer to 1.0, internal consistency of items in the scale becomes greater.[10]

The Hindi version of DASS 21 was comparable to other studies: 0.75, 0.74, and 0.79 for DASS-21 Bahasa Malaysia version,[11],[12] 0.92, 0.84, and 0.91 for DASS-21 Spanish version,[13] 0.88, 0.82, and 0.90 for English version of DASS-21 in UK population,[14] and 0.81, 0.73, and 0.81 obtained by original authors.[15] Cronbach's alpha values were also found to be between 0.86 and 0.90 in older primary care patients which was again analogous.[16]

DASS-21 Hindi version's psychometric properties are further reverberated by its validity analysis. When factor analysis using varimax rotation [Figure 1] was performed, we found the items were compatible to their related domains. Fifteen items had quite admissible values of factor loading in distinct factors. It was also concluded that item 8 under stress scale “I felt that I was using a lot of nervous energy,” item 9 under anxiety scale “I was worried about situations in which I might panic and make a fool of myself,” and item 10 under depression scale “I felt that I had nothing to look forward to” were highly saturated and were easily comprehended.
Figure 1: Depicting factor loadings in Varimax rotation (factor 1 vs factor 2)

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The concurrent validity of DASS-21 Hindi version was also evaluated in this study, by analyzing the correlations of domains in DASS with HADS. Owing to its validity to Indian population, HADS was used as reference.

The Spearman's correlation value was found to be 0.8 for depression and 0.83 for anxiety whereas 0.75 for depression and 0.66 for anxiety was recorded for Malaysian version;[17] 0.88 was recorded for anxiety and 0.93 for depression in a comparative study.[18] There was a strong correlation between both anxiety and depression domains in HADS and DASS, which suggests that the two questionnaires are apparently indistinguishable in their task and expertise. There was correlation between the two tests, as shown in a study done by Nieuwenhuijsen et al.[19]

The Spearman's correlation values between DASS and HADS came out to be more, which indicates that convergent and divergent validity were nicely assumed. The Hindi DASS-21 showed good concurrent validity with HADS as the domains of depression and anxiety were correlated strongly. It was found that DASS-21 was simple to use and was easily applicable. The results of this study have shown that DASS 21 assesses all the three psychological states of depression, anxiety, and stress simultaneously in HNC and OPMD patients.

 > Conclusions Top

Our Hindi version of DASS 21 is an added tool in hands of clinicians and researchers to diagnose depression, anxiety, and stress simultaneously among Hindi-speaking HNC patients and may aid in prompt detection and management of these conditions in HNC and precancer conditions in Indian subcontinent.


We would like to thank Dr Smita Kumar, Mani Khandpur, Saurabh Verma, and Dr Rakesh Kumar Tripathi for their contribution to the translation. We are also grateful to Dr Mukesh Srivastava for guiding us in our statistical analysis. We would also like to thank DST, Department of Science and Technology for providing the fellowship under women scientist-A scheme.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 > References Top

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Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the beck depression and anxiety inventories. Behav Res Ther 1995;33:335-43.  Back to cited text no. 15
Gloster AT, Rhoades HM, Novy D, Klotsche J, Senior A, Kunik M, et al. Psychometric properties of the Depression Anxiety and Stress Scale-21 in older primary care patients. J Affect Disord 2008;110:248-59.  Back to cited text no. 16
Ramli M, Rosnani S, Aidil Faszrul AR. Psychometric profile of Malaysian version of the Depressive, Anxiety and Stress Scale 42-item (DASS-42). Malaysia J Psychiatry 2012;21:1-7.  Back to cited text no. 17
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Nieuwenhuijsen K, de Boer AG, Verbeek JH, Blonk RW, van Dijk FJ. The Depression Anxiety Stress Scales (DASS): Detecting anxiety disorder and depression in employees absent from work because of mental health problems. Occup Environ Med 2003;60 Suppl 1:i77-82.  Back to cited text no. 19


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]

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