Translation, cross-cultural adaptation, and validation of patient component of patient and observer scar assessment scale 3.0 into Hindi

INTRODUCTION

A scar is a defect on the epithelial surface resulting from wound healing. The characteristics of a scar can vary widely and significantly influence its overall quality. A scar can be associated with functional impairments, such as restriction of motion, as well as physiological issues such as pain, hypersensitivity, and tightness. In addition, they can profoundly impact psychological well-being and quality of life.¹ The assessment of a scar is essential for monitoring changes over time, guiding treatment decisions, and evaluating surgical outcomes, including quality-of-life concerns.²

Despite the clinical significance of scar assessment, no universally acceptable or gold standard currently exists for the assessment of different aspects related to scars.^3,4 Commonly used tools include the Vancouver scar scale (VSS), modified VSS, Seattle scale, Hamilton scale, Manchester scale, patient and observer scar assessment scale (POSAS), Stony Brook scar evaluation scale, University of North Carolina 4P Scar Scale, visual analog scale, and Dermatology Life Quality Index.^2,3,5 Among these, POSAS stands out for its ability to comprehensively evaluate both clinical and quality-of-life-related aspects of scars.^5,6

POSAS was originally developed as a comprehensive tool for assessing scar quality from the perspectives of both patients and observers.⁷ The scale has undergone two major revisions. The most recent update – POSAS 3.0 – addresses the limitations of previous versions and enhances its clinical versatility.⁸ It is suitable for use across all age groups and applicable to scars arising from surgery, burns, or trauma. The scale includes two versions, one for linear scars and the other for generic scars. Each version contains two distinct but complementary questionnaires to capture the perspectives of patients and observers. The patient questionnaire evaluates six parameters: Pain, itch, sensitivity, colour, pigmentation, texture, and psychological impact, while the observer questionnaire evaluates five characteristics: Vascularity, color, pliability, texture, and cosmetic appearance. The two sets of questionnaires can be utilized independently or in tandem to provide a comprehensive assessment of scar quality.^8,9

POSAS 3.0 has been extensively used in both clinical and research settings, due to its robust validation, dual-perspective design, and distinctive characteristics.^8-10 However, its use in the Hindi-speaking population is hindered by the absence of a translated version. Given that many patients in Hindi-speaking parts of India are more comfortable in Hindi than in English, translating and culturally adapting the patient component of POSAS 3.0 is essential for broader applicability and improved patient-centered care.

The present study aimed to translate, culturally adapt, and validate the Hindi translation of the patient component of POSAS 3.0 – both generic and linear scar versions.

MATERIAL AND METHODS

A prospective, observational study was conducted from February to May 2025 at a tertiary care center to translate and validate the patient component of POSAS 3.0. Formal permission was obtained from Nederlandse Brandwonden Stichting (the scale’s licensor) to translate the scale. Institutional Ethics Committee approval was taken before study initiation. Written informed consent was obtained from all participants, and the study adhered to the ethical principles outlined in the Declaration of Helsinki.

The study included adult patients of either gender who were native Hindi speakers, presenting with healed scars resulting from previous surgeries or other etiologies. Patients with active illnesses, cognitive disorders, unhealed wounds, medically treated scars, pediatric patients, non-native Hindi speakers, or those unwilling to participate were excluded.

The study was conducted in two phases. Phase 1 involved the translation and cultural adaptation of the patient component of POSAS 3.0 (generic and linear scar versions). Phase 2 involved the assessment of the reliability and validity of the translated versions.

RESULTS

A total of 30 participants were included in the observational study, with 15 each in the generic and linear scar groups. The education level of participants ranged from matriculation to postgraduate, and all were native Hindi speakers. The generic scar group included 10 patients with scars resulting from road-traffic accidents, two from acne, and three from thermal burns. The distribution of scars included the head and neck (nine patients), limbs (five patients), and torso (one patient). All linear scars were of surgical origin and their distribution included the head and neck (six patients), limbs (eight patients), and torso (one patient). The participant characteristics are provided as Table 1.

Translation and cultural adaptation

Pilot testing of the translated POSAS 3.0 (Hindi) patient components – Generic and Linear scar versions – was conducted with 15 participants per group. All participants completed the questionnaires without major difficulty. Clarifications were provided by healthcare workers as needed, but without influencing the responses.

Feedback from participants indicated that the questions were clear and relevant. No suggestions for modification were offered by the participants. Based on these responses, the translated versions were finalized for validation. The Hindi translated versions of POSAS 3.0 Generic and Linear scar are depicted as Figures 1 and 2 respectively.

Close

Figure 1:

Final Hindi translation of POSAS 3.0 generic scar.

Export to PPT

Close

Figure 2:

Final Hindi translation of POSAS 3.0 linear scar.

Export to PPT

Reliability and validity assessment

The initial and follow-up scores for the POSAS 3.0 patient component (Generic scar [Hindi] and Linear scar [Hindi]) are provided in Table 2. The internal consistency was evaluated using Cronbach’s alpha. Both the generic and linear scar versions demonstrated high reliability, with alpha values exceeding the threshold of 0.70 in all evaluations. The generic scar version demonstrated values of 0.88 and 0.89 for the first and second assessments, respectively, while the linear scar version demonstrated even higher consistency of 0.93 and 0.94 on the two assessments, respectively. These findings confirm strong internal coherence within each scale. No alpha values exceeded 0.95, indicating an absence of redundancy among items.

Table 2: Scores and internal consistency of patient component of POSAS* 3.0 (Hindi) and scores of POSAS 2.0 (Hindi).

Translated scale version	Assessment numbera	Scoreb Mean±SDc	95% CId	Median (IQR)e	Cronbach’s alphaf	95% CId
POSAS 3.0 (Generic)	First	29.33±9.58	24.07–34.64	25 (11.5)	0.880	0.813–0.909
POSAS 3.0 (Generic)	Second	29.20±9.86	23.74–34.66	25 (12)	0.893	0.839–0.919
POSAS 3.0 (Linear)	First	39.00±16.18	30.04–47.96	34 (17)	0.932	0.770–0.967
POSAS 3.0 (Linear)	Second	39.00±16.26	29.99–48.01	33 (16)	0.937	0.788–0.967
POSAS 2.0 (Generic)	First	24.13±17.83	14.26–34.01	16 (21)	–	–
POSAS 2.0 (Generic)	Second	23.47±17.61	13.71–33.22	15 (23)	–	–
POSAS 2.0 (Linear)	First	32.60±16.53	23.44–41.76	32 (19)	–	–
POSAS 2.0 (Linear)	Second	33.27±16.02	24.39–42.14	32 (19)	–	–

*POSAS: Patient and observer scar assessment scale, aInterval between assessments=1 week, bScores range: POSAS 3.0 (Generic): 0–85, POSAS 3.0 (Linear): 0–90, POSAS 2.0: 0–70, cSD: Standard deviation, dCI: Confidence interval, eIQR: Interquartile range, fCronbach’s alpha calculated for the Hindi-translated patients’ component of POSAS 3.0 (linear and generic versions)

The test-retest reliability of the POSAS 3.0 patient component (Hindi) was assessed using Spearman’s correlation. Both the generic and linear scar versions demonstrated excellent reliability over a 1-week interval [Table 3]. For the generic scar version, the correlation between the first and second assessments was strong (ρ = 0.94, P < 0.001), with no significant difference in mean scores (29.33 ± 9.58 vs. 29.20 ± 9.86, P = 1.00). Similarly, the linear scar version showed perfect consistency (ρ = 1.00, P < 0.001), with identical mean scores across visits (39.00 ± 16.18 vs. 39.00 ± 16.26, P = 1.00).

Table 3: Reliability of the patient component of POSAS* 3.0 (Hindi) generic and linear scar versions.

Translated scale version	Assessment number	Observed scores		Test-retest reliability
		Mean (n=15)a	Significanceb	Spearman correlation coefficient	Significance
POSAS 3.0 (Generic)	First	29.33±9.58	P=1.00	ρ=0.94	P<0.001
POSAS 3.0 (Generic)	Second	29.20±9.86	95%CI=−1–−1		95% CI=1.00–0.98
POSAS 3.0 (Linear)	First	39.00±16.18	P=1.00	ρ=1.00	P<0.001
POSAS 3.0 (Linear)	Second	39.00±16.26	95% CI=−1.5–1.5		95% CI=1.00–0.99

*POSAS: Patient and observer scar assessment scale, CI: Confidence interval, ρ: Spearman correlation coefficient, ^aSample size=15 participants for both generic and linear versions of POSAS 3.0 (Hindi), ^bWilcoxon signed-rank test was used for comparing scores between 2 time points, Significant at P≤ 0.05

The validity of the newly translated POSAS 3.0 (Generic scar [Hindi] and linear scar [Hindi]) scale was evaluated against the standard POSAS 2.0 [Hindi] scale. Spearman’s correlation, RM-ANOVA, and Bland-Altman analysis were used to test the construct validity. Spearman’s correlation coefficients demonstrated moderate positive correlations between POSAS 3.0 Generic scar (Hindi) and POSAS 2.0 (Hindi) at both assessment points (ρ = 0.66 and ρ = 0.63, P < 0.05). Similarly, the correlation between POSAS 3.0 Linear scar (Hindi) and POSAS 2.0 (Hindi) at both assessment points (ρ = 0.75 and ρ = 0.77, P < 0.05) demonstrated a strong positive correlation, supporting construct validity [Table 4].

Table 4: Construct validity of patient component of POSAS* 3.0 (Hindi).

Translated scale version	Assessment number	Construct validity
		Spearman correlation coefficienta	Significance 95% CIb
POSAS 3.0 (Generic) versus 2.0	First	ρ=0.66	P=0.007 95% CI=0.94–0.51
POSAS 3.0 (Generic) versus 2.0	Second	ρ=0.63	P=0.012 95% CI=0.92–0.45
POSAS 3.0 (Linear) versus 2.0	First	ρ=0.75	P=0.001 95% CI=0.94–0.54
POSAS 3.0 (Linear) versus 2.0	Second	ρ=0.77	P<0.001 95% CI=0.95–0.59

*POSAS: Patient and observer scar assessment scale, ^aDegrees of freedom=13, Sample size=15 participants for both generic and linear versions of POSAS 3.0 (Hindi), ^bCI: Confidence interval, Significant at P≤ 0.05

RM-ANOVA showed no statistically significant difference between the scores obtained from POSAS 3.0 (Generic scar [Hindi] and Linear scar [Hindi]) and POSAS 2.0 [Hindi] scales (F = 0.01, P = 0.925 and F = 1.26, P = 0.280, respectively), nor any significant change over time (P > 0.05). The effect sizes (η²_p = 0.00–0.14) ranged from small to moderate, without statistical significance [Tables 5 and 6].

Table 5: Repeated measures ANOVA for comparison of POSAS* 3.0 (Hindi) (Generic scar) and POSAS* 2.0 (Hindi) scores across two visits.

Effect	Sum of squares	degrees of freedom	F-value	Significance	η2p
Scale (POSAS 3.0 versus POSAS 2.0)	2.79	1	0.01	P=0.925	0.00
Visit (first versus second)	4.61	1	1.12	P=0.309	0.07
Scale×Visit	2.37	1	0.41	P=0.530	0.03

*POSAS: Patient and observer scar assessment scale, ANOVA: Analysis of variance, Significant at P≤ 0.05

Table 6: Repeated measures ANOVA for comparison of POSAS* 3.0 (Hindi) (Linear scar) and POSAS* 2.0 (Hindi) scores across two visits.

Effect	Sum of squares	Degrees of freedom	F-value	Significance	η2p
Scale (POSAS 3.0 versus POSAS 2.0)	206.94	1	1.26	P=0.280	0.08
Visit (First versus second)	3.40	1	2.26	P=0.155	0.14
Scale×Visit	3.40	1	1.56	P=0.233	0.10

*POSAS: Patient and observer scar assessment scale, ANOVA: Analysis of variance, Significant at P≤ 0.05

Bland-Altman analysis [Figures 3 and 4] revealed minimal bias (−3.71–0.43). The limits of agreement for the generic and linear scar versions of the translated scales are as per Table 7. Both versions are seen to have a score-dependent divergence at the higher end of the scales.

Close

Figure 3:

Bland-Altman analysis comparing the patient components of patient and observer scar assessment scale (POSAS) 2.0 (Hindi) and POSAS 3.0 (Generic scar [Hindi]) scores. The purple zone denotes the mean difference ± 1 SD, the green zone indicates differences above the upper limit of agreement (+1.96 SD), and the pink zone indicates differences below the lower limit of agreement (−1.96 SD).

Export to PPT

Close

Figure 4:

Bland-Altman analysis comparing the patient components of patient and observer scar assessment scale (POSAS) 2.0 (Hindi) and POSAS 3.0 (Linear scar [Hindi]) scores. The purple zone denotes the mean difference ± 1 SD, the green zone indicates differences above the upper limit of agreement (+1.96 SD), and the pink zone indicates differences below the lower limit of agreement (−1.96 SD).

Export to PPT

Table 7: Bland-Altman analysis comparing POSAS* 3.0 linear and generic mean normalized scores versus POSAS* 2.0 mean normalized scores.

POSAS version	Parameter	Estimate	95% CI
POSAS 3.0 (Hindi) (Generic scar) versus POSAS 2.0 (Hindi)	Bias	0.43	−9.23–10.09
	Lower limit of agreement	−33.75	−50.63–−16.86
	Upper limit of agreement	34.61	17.72–51.49
POSAS 3.0 (Hindi) (Linear scar) versus POSAS 2.0 (Hindi)	Bias	−3.71	−10.80–3.38
	Lower limit of agreement	−28.81	−41.21–−16.41
	Upper limit of agreement	21.38	8.98–33.78

*POSAS: Patient and observer scar assessment scale, CI: Confidence interval

DISCUSSION

An effective scar assessment scale must capture both objective clinical features and subjective patient experiences. POSAS 3.0 uniquely addresses both objective and subjective domains through separate observer and patient components.³ While the POSAS 2.0 has been widely adopted for its simplicity, reliability, and multidimensionality, it had notable limitations that led to the development of POSAS 3.0. The updated version provides a more comprehensive and generalizable assessment framework, rooted in a rigorous developmental process.^8,9

The utility of POSAS 3.0 hinges on its linguistic accessibility. Administering the scale in a non-native language introduces the risk of misinterpretation, potentially affecting the score validity.^15,16 A Hindi translation of the patient component of POSAS 3.0 is therefore essential for its accurate application in the regional population.

The observer component of POSAS 3.0 uses familiar clinical terms such as colour, vascularity, pigmentation, firmness, surface, mobility, and tension. The healthcare professionals expressed a preference to continue the use of the scale in the English language in view of their professional familiarity. Thus, it was decided against translation of the observer component into Hindi as per the linguistic preference of observers and to retain clinical usefulness.

The process of cultural adaptation encountered various challenges due to the diversity of Hindi dialects across regions. The inclusion of bilingual experts with knowledge of regional dialects and variations was imperative in preserving the conceptual integrity of the questionnaire. Pre-testing of the translated version in participants with a minimum matriculation education level and sufficient knowledge of the language ensured retention of the original meaning and not oversimplifying the language. The translation process was designed to retain conceptual integrity rather than being a literal translation.

Psychometric validation supported the reliability and validity of the Hindi-translated patient scales. The internal consistency reflects the extent to which items within a given scale consistently measure the same underlying construct. Cronbach’s alpha ≥0.70 indicates acceptable internal consistency, with higher values reflecting well-correlated items. Ensuring internal consistency is particularly important in the context of translated instruments, as it confirms that the adapted items maintain coherence in meaning and measurement across linguistic and cultural contexts. In this study, Cronbach’s alpha consistently exceeded 0.88 without surpassing 0.95, confirming both strong internal consistency and absence of item redundancy.

The test-retest reliability was assessed by administering the scales twice at an interval of 1 week. Spearman’s correlation coefficient showed a strong positive correlation for both generic and linear scar versions of POSAS 3.0 (Hindi). The mean scores were also found to be statistically similar for both. These findings indicate high temporal stability of the POSAS 3.0 Hindi translations.

The validity of the scale was assessed by comparison of POSAS 3.0 (Hindi) and POSAS 2.0 (Hindi), both administered twice at an interval of 1 week. The 1-week test-retest interval minimized recall and temporal confounds.¹⁷ Construct validity was evidenced through moderate to strong correlations with the validated Hindi version of POSAS 2.0. RM-ANOVA showed the scores of both POSAS 3.0 (Hindi) (generic and linear scars) and POSAS 2.0 (Hindi) to be similar to each other, without any significant changes over time. These results suggest the stability of POSAS 3.0 (Generic scar [Hindi] and linear scar [Hindi]) and their convergent validity and interchangeability with POSAS 2.0 (Hindi) scale.

Bland-Altman analysis shows a minimal to slight negative bias in scores, without statistical significance and with wide limits of agreement. While this indicates potential variability at the individual level, it is an acceptable level of agreement for group-level comparisons. These findings suggest that POSAS 3.0 (Generic scar [Hindi] and linear scar [Hindi]) performs comparably to POSAS 2.0 (Hindi) in group-level analyses, though individual-level substitution should be interpreted with caution.

Together, these findings establish the Hindi translation of the POSAS 3.0 patient component as a psychometrically robust instrument. Its clinical relevance spans scar etiologies and locations, enhancing applicability in both routine care and research involving Hindi-speaking populations. The adoption of this translated scale will facilitate accurate scar assessment, standardize patient evaluation, and support consistent data collection for future multicentric studies. The translated versions were submitted to Nederlandse Brandwonden Stichting and are currently available online on their official website (https://www.posas.nl/downloads/).¹⁸

The study has certain inherent limitations. Photographic documentation of scar characteristics was not included, as the primary focus of the study was on the validation of subjective components of the translated scale. The sample size was modest, comprising 30 participants (15 in each group), which may restrict the generalizability of the findings.

The restricted sample size may not adequately capture variability related to dialect, literacy, cognitive status, and scar characteristics. Further studies with broader participant groups would be needed to validate and establish the robustness of the translated scale across diverse populations. While considerable effort was made to ensure linguistic clarity and cultural relevance, it is acknowledged that the Hindi language spans a wide range of dialects and cultural nuances. As such, the translated instrument may require further evaluation to ensure optimal comprehensibility across diverse Hindi-speaking populations.

CONCLUSION

The Hindi translation of the patient component of POSAS 3.0 (linear and generic scar versions) was successfully developed through a rigorous process of cross-cultural adaptation and validation. The tool demonstrates strong reliability and offers a comprehensive method for scar assessment from the patient’s perspective. Its implementation can facilitate more accurate, inclusive, and culturally appropriate scar evaluations within Hindi-speaking populations in clinical settings.