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Learn more: PMC Disclaimer | PMC Copyright Notice Int Wound J . 2026 Apr 9;23(4):e70917. doi: 10.1111/iwj.70917 Search in PMC Search in PubMed View in NLM Catalog Add to search Translation, Validation and Cross‐Cultural Adaptation of the Patient and Observer Scar Assessment Scale Version 3.0 (POSAS 3.0) Into Malay Language for Injury‐Related Scar Ken Wong Siong Hou Ken Wong Siong Hou 1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Find articles by Ken Wong Siong Hou 1 , Gan Chun Hong Gan Chun Hong 2 Clinical Psychology and Behavioural Health Programme, Center for Rehabilitation and Special Needs Studies, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Find articles by Gan Chun Hong 2 , Mohd Johar Jaafar Mohd Johar Jaafar 3 Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Find articles by Mohd Johar Jaafar 3 , Roszalina Ramli Roszalina Ramli 1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Find articles by Roszalina Ramli 1, ✉ Author information Article notes Copyright and License information 1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 2 Clinical Psychology and Behavioural Health Programme, Center for Rehabilitation and Special Needs Studies, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 3 Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia * Correspondence: Roszalina Ramli ( [email protected] ) ✉ Corresponding author. Revised 2026 Mar 31; Received 2025 Dec 4; Accepted 2026 Apr 6; Collection date 2026 Apr. © 2026 The Author(s). International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd. This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. PMC Copyright notice PMCID: PMC13065433 PMID: 41956909 ABSTRACT Patient and Observer Scar Assessment Scale Version 3.0 (POSAS 3.0) is a robust instrument for scar evaluation. Currently, no validated POSAS 3.0 in the Malay language is available. This study aimed to translate, culturally adapt, and psychometrically evaluate POSAS 3.0 for Malay‐speaking populations in Malaysia. Malaysian patients were recruited between 31 October 2023, to 31 December 2024. Translation was conducted using a forward and backward translation approach. Reliability was assessed using internal consistency (Cronbach's alpha) and test–retest. Face validity was addressed with 10 patients, and content validity was evaluated by four clinical specialists. Content validity was evaluated using the item‐content validity index (I‐CVI) and content validity ratio (CVR). Construct validity was assessed using exploratory factor analysis (EFA). Seventy‐eight participants with facial ( n = 39, 50.0%) and non‐facial ( n = 39, 50.0%) soft tissue scars were recruited for the EFA. The Malay POSAS‐O demonstrated acceptable internal consistency ( α = 0.75) and excellent inter‐rater reliability, with item‐level intraclass correlation coefficient (ICCs) ranging from 0.91 to 1.00 and total score ICC of 0.99. Agreement for categorical scar severity ratings was almost perfect (κ = 0.89). The Malay POSAS‐P showed excellent internal consistency ( α = 0.89), and test–retest reliability for the total score was good to excellent (ICC = 0.89). Intermittent symptom items (painful, shooting, burning and fragile) exhibited lower stability, reflecting natural symptom variability. Content validity was excellent, with all items achieving I‐CVI and CVR values of 1.00. EFA supported construct validity, with adequate Kaiser‐Meyer‐Olkin (KMO) values (POSAS‐O: 0.88; POSAS‐P: 0.85), significant Bartlett's tests, strong communalities and factor loadings. The cumulative variance explained was 79.05% for POSAS‐O and 68.19% for POSAS‐P. The Malay version of the POSAS 3.0 is a reliable, valid, and culturally appropriate instrument for scar assessment. Its strong psychometric properties support its application in clinical practice and research involving Malay‐speaking populations. Keywords: cross‐cultural adaptation, Malay, POSAS 3.0, translation, validation Key Messages The Patient and Observer Scar Assessment Scale (POSAS) 3.0 was successfully translated and culturally adapted into the Malay language using standard translation procedures. The Malay POSAS Observer Scale 3.0 demonstrated acceptable internal consistency and excellent inter‐rater reliability, with near‐perfect agreement in categorical scar severity ratings. The Malay POSAS Patient Scale 3.0 showed excellent internal consistency and good to excellent test–retest reliability, although intermittent symptom items reflected expected natural variability. The validated Malay POSAS 3.0 provides a reliable, valid and culturally appropriate tool for clinical and research assessment of scars among Malay‐speaking populations. 1. Introduction Scar appearance varies significantly according to anatomical location, patient‐specific factors, including ethnicity, mechanism of injury, and local wound‐healing conditions. Additionally, associated symptoms such as pruritus, pain, and tissue tension contribute substantially to the overall scar burden and profoundly influence the patient‐reported experience [ 1 ]. Scar is highly prevalent worldwide and constitutes a substantial public health and clinical burden, with clear relevance to Malay‐speaking populations in Southeast Asia. These populations are primarily found in Malaysia, Indonesia, Brunei Darussalam, and Singapore. In a large international survey of adults, approximately one in two respondents reported at least one recent scar, with a considerable proportion experiencing symptomatic sequelae such as pain and pruritus [ 2 ]. The World Health Organization estimates that nearly 11 million burn injuries require medical attention annually worldwide [ 3 ], while an estimated 312.9 million surgical procedures were performed globally in 2012 alone, each carrying the potential for clinically meaningful scar formation [ 4 ]. Reported prevalence rates of hypertrophic scarring range from approximately 32% to 72% [ 5 ], and wide variability in incidence following surgery and burns has been documented across studies [ 6 ]. In Asian populations, the annual incidence of keloids has been estimated at approximately 0.15% [ 7 ], and genetic susceptibility to keloid formation has been demonstrated in the Malay population [ 8 ]. Collectively, these data underscore the clinical and epidemiological imperative for robust, culturally appropriate scar outcome measures in Malay‐speaking settings. Assessment of scars requires a comprehensive approach that combines both objective and subjective measures. Various tools have been developed to evaluate different scar characteristics such as appearance, texture, thickness, pigmentation, and the patient's subjective experience. These tools are generally categorised into four groups: objective measurement tools, clinician‐reported outcome measures (CROMs), patient‐reported outcome measures, and combined tools that integrate both clinician and patient perspectives [ 9 ]. There are several scales that entail these requirements, but the Patient and Observer Scar Assessment Scale (POSAS), developed by Draaijers et al., is the most robust instrument for the evaluation of scars because it also attributes weight to the patient's opinion [ 10 ]. The POSAS is designed to address the multifaceted nature of scarring by integrating both clinician assessments and patient‐reported outcomes [ 11 , 12 ]. It was developed in response to the limitations of earlier tools that focused predominantly on clinical features, thereby neglecting the subjective experiences of individuals living with scars. POSAS has undergone several iterations, with the latest version, POSAS 3.0, reflecting improved clarity, updated scoring anchors, and enhanced relevance for a wider range of scar types and clinical settings [ 11 ]. POSAS 3.0 was launched in 2022 and consists of two complementary components: the Observer Scale, completed by a trained clinician or healthcare provider, and the Patient Scale, completed by the person with the scar ( https://www.posas.nl/about/ ) [ 13 ]. The Observer Scale evaluates nine parameters and the Patient Scale has seventeen items [ 13 ]. POSAS emphasises clear definitions and visual anchors for each score to enhance consistency and ease of use. To date, POSAS 3.0 has been translated into 23 languages [ 13 ], however, a Malay version has yet to be developed. The objective of this study was to translate, culturally adapt, and psychometrically evaluate POSAS 3.0 for use among Malay‐speaking populations in Malaysia. 2. Methodology 2.1. Study Design and Setting A prospective observational study on the translation, cultural adaptation, and psychometric evaluation of POSAS 3.0 into Malay was conducted at a university hospital in Kuala Lumpur, Malaysia, from 31 October 2023 to 31 December 2024. 2.2. Ethical Approval Ethical approval was obtained from the Research Ethics Committee, The National University of Malaysia (UKM PPI/111/8/JEP‐2023‐414). Written informed consent was obtained from all participants prior to enrolment, and the study was conducted in accordance with the Declaration of Helsinki. 2.3. Translation and Cultural Adaptation Procedure The English version of POSAS 3.0 was translated into Malay using a standardised forward‐backward translation method consistent with widely used cross‐cultural adaptation guidance [ 14 , 15 , 16 ]. This process was conducted with permission from the original POSAS developers and comprised the following steps as shown below and in Figure 1 . FIGURE 1. Open in a new tab Process of translation and cross‐cultural adaptation of POSAS 3.0 (Figure drawn using Canva). 2.3.1. Step 1: Forward Translation Two independent bilingual translators (fluent in English and Malay) whose mother tongue was Malay produced two forward translations of the POSAS 3.0. One translator was a medical professional familiar with scar assessment terminology, and the other was a professional translator without a medical background to ensure colloquial readability. They translated all components of POSAS 3.0, including item descriptions, response options, and instructions, into Malay. 2.3.2. Step 2: Synthesis of the Forward Translation The research team, including the translators and a moderator, compared the two Malay forward translations item by item. Discrepancies or differences in wording were discussed, and a single reconciled Malay draft (version 1) of the POSAS 3.0 was synthesised. Emphasis was placed on conceptual equivalence rather than literal translation to preserve the meaning of terms like ‘pliability’ or ‘itch’ in culturally appropriate language. 2.3.3. Step 3: Back Translation Two different independent translators, whose first language was English and who were blinded to the original POSAS 3.0 phrasing, translated the Malay draft back into English. Neither of these translators had seen the original English POSAS 3.0 prior, serving as a validity check that the Malay wording had not deviated in meaning. 2.3.4. Step 4: Expert Committee Composes the Pre‐Final Version An expert committee of three bilingual translators was established. The committee comprised a researcher (oral and maxillofacial surgery [OMFS] trainee), an OMFS consultant acting as methodologist and clinical expert, and a language professional (qualified translator). The committee reviewed all translations and accompanying reports. The developers of the original questionnaire (the research group of Professor Dr. Paul van Zuijlen for the POSAS 3.0) were contacted to confirm that the translated items preserved their intended meaning. Any discrepancies were discussed until consensus was reached, and a pre‐final Malay version was drafted, with a written report documenting all considerations and decisions. The same expert committee then systematically reviewed all versions (original English, forward translations, reconciled Malay draft, and back‐translations). They evaluated Malay Version 1 for semantic, idiomatic, experiential, and conceptual equivalence. Problematic items were identified and refined. For example, the term ‘stiffness’ in the context of a scar was initially translated to a Malay word meaning general rigidity; the committee adjusted it to a phrase meaning ‘skin tightness’ to better reflect scar pliability. Similarly, the response scale descriptors (which in POSAS 3.0 use verbal anchors for a 5‐point scale) were carefully adapted; for instance, ‘like normal skin’ was translated to ‘seperti kulit normal’ and ‘worst imaginable scar’ to ‘parut paling teruk yang boleh dibayangkan,’ ensuring clarity at each end of the scale. The committee achieved consensus on Malay Version 2 of the POSAS 3.0. 2.3.5. Step 5: Test of the Pre‐Final Version Malay Version 2 was pilot‐tested on a group of 10 adult participants with facial scars (these participants were not included in the main study sample). Each participant completed the Malay POSAS 3.0 and was then interviewed to probe their understanding of each item and response option. We asked patients to paraphrase questions (e.g., ‘What does this question about scar colour mean to you?’) and to describe how they chose their answers. Feedback indicated that the items were generally clear, with a few minor linguistic adjustments made for clarity. 2.3.6. Step 6: Appraisal of the Adaptation Process by the Developers All translations and written reports were sent to the original developers of the questionnaire for the audit process. After their approval, the translated questionnaire was ready for cross‐cultural validation. 2.4. Reliability Tests To evaluate the reliability of Malay POSAS 3.0, internal consistency, instrument stability (test–retest reliability), and inter‐rater reliability were examined. 2.4.1. Internal Consistency Internal consistency was assessed using Cronbach's alpha coefficient, with values: α ≥ 0.9 = excellent, 0.9 > α ≥ 0.8 = good, 0.8 > α ≥ 0.7 = acceptable, 0.7 > α ≥ 0.6 = questionable, 0.6 > α ≥ 0.5 = poor, 0.5 > α = unacceptable [ 17 ]. 2.4.2. Instrument Stability Instrument stability was evaluated using a test–retest approach involving 35 participants. In this study, the questionnaire was administered twice with a 14‐day interval, and the resulting scores were compared using the intraclass correlation coefficient (ICC), based on a two‐way random‐effects, absolute‐agreement, single‐measure model [ICC (2,1)]. The absolute‐agreement definition was selected because test–retest reliability evaluates reproducibility of the same scores across repeated administrations, rather than rank‐order consistency alone. ICC values were interpreted as follow. Values less than 0.5 indicating poor reliability, 0.5 to less than 0.75 indicating moderate reliability, 0.75 to less than 0.9 indicating good reliability, and 0.90 to 1.00 indicating excellent reliability [ 18 ]. 2.4.3. Inter‐Rater Reliability Inter‐rater reliability of the Observer Scale (POSAS‐O) was evaluated using ratings from two assessors on the same scars. Agreement for the POSAS‐O total score was assessed using the ICC based on a two‐way random‐effects, absolute‐agreement, single‐measure model [ICC (2,1)]. For item‐level observer ratings (ordinal scale items), agreement between raters was assessed using Cohen's kappa (weighted kappa for ordinal agreement). Kappa strength categories were interpreted using Landis and Koch [ 19 ]. 2.5. Validation Tests Three main forms of validity were assessed: face validity, content validity and construct validity. 2.5.1. Face Validity A sample of 35 participants was utilised, in accordance with the recommendation by Yusoff [ 20 ], with the same participants also contributing to the reliability assessment. The participants completed the questionnaire via Google Form and subsequently participated in one‐on‐one semi‐structured in‐depth interviews to explore their comprehension and interpretation of each questionnaire item. The expert panel then thoroughly reviewed the findings, focusing on the difficulties encountered and the suggestions provided by the participants. Based on this feedback, the final version of the questionnaire was developed and subsequently subjected to validity and reliability testing. 2.5.2. Content Validity Content validity is vital to ensure the overall validity of an assessment [ 20 ]. The content validity of the translated Malay version of the POSAS 3.0 was evaluated to ensure the relevance, clarity, and cultural appropriateness of each item. The validation process involved an expert panel consisting of at least two professionals [ 20 ]. For this study, four assessors who were clinical specialists with more than 7 years of experience were selected. Each expert independently assessed the items for representativeness, relevance, and clarity, using a 4‐point ordinal scale (1 = not relevant, 4 = highly relevant) and necessity (3‐ordinal scale) (Figure 2 ). Representativeness, relevance, and clarity were evaluated using a 4‐point ordinal scale and analysed through the item‐content validity index (I‐CVI) [ 20 ]. The I‐CVI was determined by dividing the number of experts who rated an item as 3 or 4 by the total number of experts [ 20 ]. An I‐CVI value of 0.78 or higher was deemed acceptable [ 21 ]. Necessity was assessed using a 3‐point ordinal scale and analysed using the content validity ratio (CVR). The CVR was computed using the formula ‘CVR = (Ne − N /2)/(N/2)’, where N represents the total number of experts and Ne denotes the number of experts who rated the item as essential (score of 3). A CVR of at least 0.78 was considered acceptable [ 22 ]. FIGURE 2. Open in a new tab Scale for representativeness, relevancy, clarity and necessity of a questionnaire. 2.5.3. Construct Validity Exploratory factor analysis (EFA) was conducted to identify the underlying structure within a relatively large set of variables. The recommended minimum sample size for EFA is between 3 and 10 participants per item [ 23 ]. Since POSAS 3.0 comprises 26 items, the minimum required sample size was 78. The Kaiser‐Meyer‐Olkin (KMO) test and Bartlett's test of sphericity were performed to assess sampling adequacy and the suitability of the data for factor analysis [ 24 ]. A KMO value closer to 1 indicates greater suitability for factor analysis; generally, values above 0.5 are acceptable and those above 0.7 are considered more appropriate [ 24 ]. A p value of less than 0.05 in Bartlett's test indicates statistical significance [ 25 ]. Principal component analysis (PCA) was applied to extract the maximum amount of variance from the dataset for each component. The Total Variance Explained table illustrates how variance is distributed among the POSAS items. According to the Kaiser criterion, components with eigenvalues greater than 1 should be retained, as they explain more variance than a single item, thereby justifying the grouping of those items into a factor [ 26 ]. However, this assumption is valid only when each item contributes one unit of variance. Pett et al. suggested that the Kaiser criterion should only be applied in PCA when the total variance is considered during extraction [ 27 ]. 2.6. Participants and Eligibility Criteria The study population comprised adults with injury‐related scars located at both facial and non‐facial anatomical sites who received treatment at the study centre. Inclusion criteria were: age 18 years and above, ability to read Malay, presence of an injury‐related scar located on the face or other body sites, and scar duration of at least 3 months post‐injury at the time of POSAS administration to ensure that scar features relevant to POSAS 3.0 items (e.g., pigmentation and stiffness) were clinically assessable. Exclusion criteria were cognitive impairment precluding reliable self‐report or major psychiatric illness affecting participation. 2.7. Recruitment and Enrolment Procedure Participants were recruited via a service‐based pathway from three clinical sources: (1) the Emergency Department, (2) the Oral and Maxillofacial Surgery and Plastic and Reconstructive Surgery wards, and (3) relevant outpatient clinics. Potentially eligible patients presenting with acute injury‐related wounds were identified by the clinical team and/or research personnel and screened against the eligibility criteria. Patients who met preliminary criteria were approached in person, provided with study information, and invited to participate. To standardise the timing of scar assessment, POSAS 3.0 was not administered during the acute wound phase. Instead, participants were given a follow‐up appointment at 3 months post‐injury, at which time POSAS 3.0 was administered. Reminder procedures (e.g., telephone or messaging reminders) were used according to clinic routine to support attendance. At the 3‐month visit, written informed consent was reconfirmed where applicable. Baseline information was recorded using a standardised case report form, including age, sex, ethnicity, education level, injury mechanism, anatomical scar site (facial vs. non‐facial), time since injury, and relevant clinical details of the injury and its management. Questionnaire completeness was checked at the point of collection; in this study, all enrolled participants completed the questionnaire with no missing item responses. 2.8. Study Instruments and Administration 2.8.1. Demographic and Clinical Information Questionnaire A study proforma was used to collect the demographic and clinical information such as age, gender, ethnic group, and other information. 2.8.2. POSAS 3.0 Just like the previous two versions, POSAS 3.0 consisted of the Patient Scale and the Observer scale. Each scale was further divided into Linear Scar version, for surgical wounds or clean wounds and Generic version for all types of wounds. The Patient‐Generic version comprised 16 items, whereas the Patient‐Linear Scar version included the same 16 items plus an additional item addressing scar edge widening, resulting in a total of 17 items. The Observer Scale consisted of seven items, with two additional items incorporated in the Linear Scar version. All included items were rated on a verbal rating scale with five response options. Items in the Patient Scale included: (i) colour, (ii) shininess, (iii) surface level (raised/sunken), (iv) hardness, (v) irregularity, (vi) scar edges, (vii) sensitiveness, (viii) numbness, (ix) pain, (x) shooting sensation, (xi) burning sensation, (xii) itch, (xiii) tingling, (xiv) scar tightness at rest, (xv) tightness during movement, (xvi) fragility and (xvii) dryness. Items in the Observer Scale comprised: (i) pigmentation, (ii) vascularity, (iii) surface level, (iv) surface texture, (v) firmness, (vi) adhering, (vii) tension, (viii) widening of the edges and (ix) marks resulting from surgical wound closure. 2.9. Sample Size The total sample comprised 78 participants. Of these, 35 participants were included in the assessment of face validity and test–retest reliability. This subsample size aligns with established guidance for cross‐cultural adaptation and field testing of translated patient‐reported outcome measures, which commonly recommends approximately 30–40 participants and was supported by feasibility considerations for a single‐centre psychometric evaluation [ 15 , 28 ]. This number was considered adequate for estimating internal consistency and test–retest reliability and is comparable to sample sizes used in prior POSAS translation and validation studies [ 29 ]. To further examine the underlying structure of the instrument, EFA was conducted using the full sample of 78 participants as a preliminary assessment of structural validity. While larger samples are generally recommended for factor analytic procedures, EFA may still provide useful preliminary insights when conducted with modest sample sizes, particularly when supported by measures of sampling adequacy. Accordingly, the factor analytic findings in this study were interpreted as exploratory, and should be confirmed in larger multicentre samples using confirmatory factor analysis, consistent with recommendations from the COSMIN initiative for psychometric evaluation [ 30 ]. 3. Results 3.1. Study Population All enrolled participants completed the questionnaire, with no missing item responses. The study sample ( N = 78) was predominantly male (61.5%) and Malay (70.5%), with the majority aged 18–34 years (53.8%). Most participants had attained tertiary education (70.5%), and equivalent proportions of facial and non‐facial soft tissue injuries (50.0% and 50.0%), reflecting a relatively young, well‐educated cohort primarily comprising patients with facial and non‐facial trauma (Table 1 ). TABLE 1. Subject demographics for reliability and validity tests. Characteristics Participants ( N = 78) n (%) Gender Male 48 (61.5) Female 30 (38.5) Ethnicity Malay 55 (70.5) Chinese 17 (21.8) Indians 4 (5.1) Others 2 (2.6) Age (years) 18 to 34 42 (53.8) 35 and above 36 (46.2) Education level Primary & secondary 23 (29.5) Tertiary 55 (70.5) Location of injury NFSTI 39 (50.0) FSTI 39 (50.0) Duration since injury at assessment 3 to 6 months 78 (100.0) > 6 months 0 (0.0) Open in a new tab The study was conducted in multiple stages in accordance with the methodology described by Khan et al. and Saw et al. [ 31 , 32 ]. Initial reliability and validity assessments were performed on a subset of 35 participants. Subsequently, the sample size was expanded to 78 participants to fulfil the recommended requirements for construct validity analysis. Abbreviations: FSTI: facial soft tissue injury; NFSTI: non‐facial soft tissue injury. 3.2. POSAS 3.0 Observer Scale Reliability 3.2.1. Internal Consistency The POSAS 3.0 Observer Scale (POSAS‐O) subscale presented acceptable internal consistency, with a Cronbach's alpha of 0.75. Corrected item‐total correlations ranged from 0.33 (surface texture) to 0.65 (adherence), indicating moderate correlations across observer‐rated items and supporting the internal coherence of the observer scale in this subsample. 3.2.2. Inter‐Rater Reliability Inter‐rater reliability for the Malay POSAS‐O was evaluated in 35 scars independently scored by two clinicians on all seven POSAS‐O items (pigmentation, vascularity, surface level, surface texture, firmness, adherence, tension). A two‐way random‐effects, absolute‐agreement, single‐measure intraclass correlation coefficient ICC (2,1) was used, as recommended by Koo and Li [ 18 ]. Item‐wise ICC (2,1) values ranged from 0.91 to 1.00, indicating excellent inter‐rater reliability for all observer‐rated items, and the total POSAS‐O score showed ICC = 0.99, also within the ‘excellent’ range (Table 2 ). TABLE 2. Inter‐rater reliability (ICC). Item ICC (2,1) 95% CI Interpretation * Pigmentation 1.00 0.99–1.00 Excellent Vascularity 1.00 0.99–1.00 Excellent Surface level 0.99 0.99–0.99 Excellent Surface texture 0.99 0.99–1.00 Excellent Firmness 1.00 1.00–1.00 Excellent Adherence 0.99 0.99–0.99 Excellent Tension 1.00 1.00–1.00 Excellent Total score 0.99 0.99–1.00 Excellent Open in a new tab * Interpretation based on commonly used ICC guidelines (ICC > 0.90 = excellent agreement). For clinical interpretability, total scores were further grouped into five categories (Not, Minimal, Moderate, Severe, Extreme). Using these categories, the two raters agreed on 33/35 scars (94.3% agreement), yielding an unweighted Cohen's kappa of 0.89, which corresponds to ‘almost perfect’ agreement according to Landis and Koch [ 19 ]. Overall, these findings demonstrate that the Malay POSAS‐O can be applied with highly consistent ratings between clinicians in this setting. 3.3. POSAS 3.0 Patient Scale (POSAS‐P) Reliability 3.3.1. Internal Consistency The POSAS‐P subscale demonstrated good internal consistency, with a Cronbach's alpha of 0.89 in the 35‐participant subsample, which exceeded the predefined acceptability threshold of > 0.70. 3.3.2. Test–Retest Reliability Test–retest reliability of the Malay POSAS‐P scale was evaluated in 35 scars rated on two occasions with a 14‐day interval. Reliability was assessed using the ICC based on a two‐way random‐effects model with absolute agreement for single measurements [ICC (2,1)], with results reported alongside 95% confidence intervals. A 14‐day retest interval was selected based on COSMIN guidance, which recommends a period long enough to minimise recall of prior responses but short enough to ensure that the construct is unlikely to have changed [ 33 ]. In the absence of new interventions, scar status is expected to remain stable over 2 weeks, allowing a valid assessment of test–retest reliability. The POSAS‐P total score demonstrated good‐excellent temporal stability (ICC = 0.89). Item‐level ICC (2,1) values ranged from 0.14 (fragile) to 0.90 (irregular). Most appearance and static symptom items, such as colour, raised/sunken, hard, irregular, tingling, tight at rest and pulls tight on movement, showed good‐excellent reliability (ICC ≥ 0.77), whereas intermittent symptom items (painful, shooting, burning and fragile) showed lower stability (ICC = 0.14 to 0.40), consistent with genuine fluctuation in these complaints over time rather than measurement error. 3.4. Validity Tests 3.4.1. Face Validity Test In the face validity test, only minor adjustment was made, for example, the Malay word for ‘tingling’ (one of the POSAS‐P's sensation items) was unfamiliar to some, so an alternative common term was provided in parentheses. Overall, the instrument required no major changes, confirming that the Malay POSAS 3.0 was easily comprehensible for the target population. 3.4.2. Content Validity Test The uniformly high item‐level content validity index (I‐CVI) and CVR values (all = 1.00) demonstrate excellent content validity for both POSAS‐O and POSAS‐P in the translated version (Table 3 ). These findings indicate that: All items are essential and appropriate for inclusion. No item requires modification or removal based on expert evaluation. The translated POSAS 3.0 maintains strong conceptual and linguistic equivalence with the original scale. TABLE 3. Results for content validity results for the Malay POSAS 3.0 (POSAS‐O and POSAS‐P). I‐CVI representativeness I‐CVI relevance I‐CVI clarity CVR POSAS‐O Pigmentation 1.00 1.00 1.00 1.00 Vascularity 1.00 1.00 1.00 1.00 Surface level 1.00 1.00 1.00 1.00 Surface texture 1.00 1.00 1.00 1.00 Firmness 1.00 1.00 1.00 1.00 Adherence 1.00 1.00 1.00 1.00 Tension 1.00 1.00 1.00 1.00 Widening of the edges 1.00 1.00 1.00 1.00 Marks resulting from surgical wound closure 1.00 1.00 1.00 1.00 POSAS‐P Colour 1.00 1.00 1.00 1.00 Shininess 1.00 1.00 1.00 1.00 Surface level (raised/sunken) 1.00 1.00 1.00 1.00 Hardness 1.00 1.00 1.00 1.00 Irregularity 1.00 1.00 1.00 1.00 Scar edges 1.00 1.00 1.00 1.00 Sensitiveness 1.00 1.00 1.00 1.00 Numbness 1.00 1.00 1.00 1.00 Pain 1.00 1.00 1.00 1.00 Shooting sensation 1.00 1.00 1.00 1.00 Burning sensation 1.00 1.00 1.00 1.00 Itchiness 1.00 1.00 1.00 1.00 Tingling sensation 1.00 1.00 1.00 1.00 Scar tightness at rest 1.00 1.00 1.00 1.00 Tightness during movement 1.00 1.00 1.00 1.00 Fragility 1.00 1.00 1.00 1.00 Dryness 1.00 1.00 1.00 1.00 Open in a new tab Abbreviations: CVR = content validity ratio; I‐CVI = Item‐level Content Validity Index. Such results support the use of POSAS‐P and POSAS‐O as content‐valid instruments for evaluating scars in the Malay‐speaking population. 3.4.3. Construct Validity Test EFA using PCA with oblimin rotation was conducted to examine the construct validity of the Malay version of the POSAS‐O and POSAS‐P. In the present study, all initial communalities were above the threshold of 0.3 [ 32 , 34 ] and all loading factors were above 0.5 [ 32 ]. 3.4.3.1. POSAS‐O The Kaiser–Meyer–Olkin (KMO) value was 0.88, indicating meritorious adequacy. Bartlett's test of sphericity was significant ( χ 2 = 544.77, df = 36, p < 0.001), suggesting that the correlation matrix was suitable for factor analysis (Table 4 ). The analysis extracted two components with eigenvalues greater than 1, accounting for a substantial proportion of the total variance. The communalities ranged from 0.72 to 0.87, indicating that all items were well represented by the extracted components (Table 5 ). TABLE 4. KMO and Bartlett's test of sphericity for POSAS‐O and POSAS‐P. KMO Bartlett's test of sphericity Cumulative variance POSAS‐O 0.88 χ 2 = 544.77, df = 36, p < 0.001 79.05% POSAS‐P 0.85 χ 2 = 914.20, df = 120, p < 0.001 68.19% Open in a new tab TABLE 5. Communalities and factor loadings from EFA of POSAS‐O and POSAS‐P. Item Communalities Factor 1 Factor 2 Factor 3 POSAS‐O Adherence 0.87 0.98 −0.12 Firmness 0.80 0.93 0.08 Tension 0.72 0.83 −0.03 Surface level 0.79 0.75 −0.23 Surface texture 0.76 0.60 −0.40 Pigmentation 0.78 −0.06 −0.91 Vascularity 0.81 0.00 −0.90 Widening of the edges 0.80 0.03 −0.88 Marks resulting from wound closure 0.81 0.06 −0.87 POSAS‐P Pain 0.73 0.80 0.29 −0.01 Tightness during movement 0.83 0.79 −0.02 −0.45 Sensitiveness 0.69 0.79 0.14 0.21 Surface level 0.84 0.79 −0.43 0.19 Colour 0.76 0.77 −0.29 0.30 Numbness 0.67 0.75 0.15 −0.28 Dryness 0.70 0.75 0.15 −0.32 Itchiness 0.56 0.72 −0.18 −0.03 Scar tightness at rest 0.89 0.70 0.14 −0.62 Hardness 0.59 0.68 −0.34 0.04 Shininess 0.55 0.68 −0.14 0.27 Surface texture (irregularity) 0.79 0.66 −0.59 0.12 Fragility 0.51 0.64 0.20 0.24 Shooting sensation 0.70 0.61 0.45 0.36 Tingling sensation 0.41 0.60 0.15 −0.15 Burning sensation 0.73 0.41 0.65 0.36 Open in a new tab Note: Communalities: Numbers in bold are above the threshold of 0.3; Loading factors: Numbers in bold are above the threshold of 0.5. Based on the pattern matrix with oblimin rotation, five items (adherence, firmness, tension, surface level, and surface texture) loaded strongly on Factor 1, while four items (pigmentation, vascularity, widening of the edges and marks resulting from wound closure) loaded strongly on Factor 2, with factor loadings ranging from 0.60 to 0.98 in absolute values. 3.4.3.2. POSAS‐P The suitability of the data for factor analysis was confirmed by the Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy and Bartlett's test of sphericity. The KMO value was 0.85, indicating good sampling adequacy. Bartlett's test of sphericity was statistically significant ( χ 2 = 914.20, df = 120, p < 0.001), demonstrating that the correlation matrix was suitable for factor analysis (Table 4 ). Communality values ranged from 0.41 to 0.89, indicating that a substantial proportion of variance in each item was explained by the extracted components (Table 5 ). PCA identified three components with eigenvalues greater than 1, which together explained 68.19% of the total variance. The first factor accounted for 49.49%, the second 10.24%, and the third 8.46% of the variance. Most items demonstrated strong factor loadings (0.60 to 0.80), indicating that the items contributed meaningfully to the underlying construct measured by the POSAS‐P. 4. Discussion The POSAS 3.0 was successfully translated and culturally adapted into Malay. The Malay version demonstrated robust psychometric properties, including excellent content validity, acceptable internal consistency, and strong test–retest reliability among Malay‐speaking patients with scars. These findings support its application for scar assessment in both clinical practice and research settings in Malaysia. Furthermore, the questionnaire showed high acceptability, with no missing item responses in the final analytic sample. The POSAS 3.0 had been validated in studies conducted in Italy and Russia, demonstrating its validity and reliability as an instrument for assessing post‐surgical scars [ 11 , 35 ]. The present findings are consistent with these reports and further support its applicability in Malay‐speaking populations. The Malay POSAS‐O demonstrated strong psychometric performance. Internal consistency was acceptable (Cronbach's alpha of 0.75) and comparable with previously published POSAS validations [ 16 , 29 ]. Importantly, inter‐rater reliability was excellent across all items and for the total score, indicating that clinicians can apply the scale with high reproducibility, with item‐wise ICC (2,1) values ranging from 0.91 to 1.00 and a total score ICC of 0.99. The very high agreement in categorical ratings further reinforces its utility in everyday clinical decision‐making, where consistency between clinicians is essential with 33/35 (94.3%) agreement and Cohen's kappa of 0.89. The Malay POSAS‐P showed excellent internal consistency, consistent with other language versions of the instrument, with a Cronbach's alpha of 0.89. Corrected item‐total correlations were acceptable overall (0.26 to 0.84), and Cronbach's alpha did not increase meaningfully when any item was deleted (0.88 to 0.90), supporting retention of all items. Test–retest reliability of the total score was also strong (ICC = 0.89). As anticipated, intermittent symptom‐related items demonstrated lower temporal stability. This pattern is well recognised in patient‐reported outcome measures, as symptoms such as pain and burning naturally fluctuate over time. In this study, item‐level ICC values ranged from 0.14 (fragile) to 0.90 (irregular), and intermittent symptom items (painful, shooting, burning and fragile) showed lower stability (ICC 0.14 to −0.40), supporting that variability reflects genuine symptom fluctuation rather than instability of the scale itself. The content validity was excellent, with unanimous expert agreement that all items were essential and conceptually appropriate, as reflected by I‐CVI and CVR values of 1.00 for all items. This finding indicates that the translation and cultural adaptation process successfully preserved the intended meaning of the original POSAS 3.0. Both the observer and patient scales demonstrated good sampling adequacy and factorability, with satisfactory KMO values and significant Bartlett's tests (POSAS‐O: KMO = 0.88; Bartlett's test χ 2 = 544.77, df = 36, p < 0.001; POSAS‐P: KMO = 0.85; Bartlett's test χ 2 = 914.20, df = 120, p < 0.001). The extracted factor structures accounted for a substantial proportion of variance (79.05% for POSAS‐O and 68.19% for POSAS‐P). Communalities ranged from 0.72 to 0.87 for POSAS‐O and from 0.41 to 0.89 for POSAS‐P. The POSAS‐O demonstrated a two‐factor structure, with five items (adherence, firmness, tension, surface level, and surface texture) loading strongly on Factor 1, and four items (pigmentation, vascularity, widening of the edges, and marks resulting from wound closure) loading strongly on Factor 2, with factor loadings ranging from 0.60 to 0.98 in absolute values. In contrast, the POSAS‐P exhibited a three‐factor structure, with most items showing strong loadings (0.60–0.80). Fifteen items, including pain, tightness during movement, sensitiveness, surface level, colour, numbness, dryness, itchiness, scar tightness at rest, hardness and shininess, loaded strongly on Factor 1, while burning sensation loaded strongly on Factor 2. This study is particularly important as the POSAS 3.0 is not merely a revised version of earlier POSAS instruments. Compared with previous versions, including POSAS 2.0 used in some settings, POSAS 3.0 incorporates refined wording, clearer scoring anchors, and expanded patient‐reported domains to more comprehensively capture scar symptoms and patient experiences across diverse scar types. Consequently, psychometric evidence from earlier versions cannot be assumed to be directly applicable to POSAS 3.0, underscoring the need for a dedicated Malay translation and validation of this version. The Malay POSAS 3.0 provides clinicians in Malaysia with a culturally adapted and validated tool for scar assessment across different clinical settings. The excellent inter‐rater reliability of the Observer Scale supports its use in multidisciplinary practice, while the Patient Scale provides a reliable way to capture patient‐centred outcomes. As shown in other POSAS 3.0 validation studies, a locally validated version improves confidence in clinical and research use [ 11 , 35 ]. Given the burden of injury‐related and surgical scars in Malaysia, the Malay POSAS 3.0 may improve clinical documentation and support research on scar quality, treatment outcomes, and longitudinal scar progression. Healing of soft tissue wound is a complex molecular process. Fibrosis is closely associated with wound healing and is one of the leading causes of wound‐related morbidity. While scar formation is a natural and unavoidable part of adult mammalian cutaneous wound healing, the severity and characteristics of scarring can differ greatly between various anatomical locations [ 1 , 5 ]. An ideal mature scar is typically narrow, flat, and blends with the surrounding skin, whereas unfavourable scars include hypertrophic and keloid scars, which are raised and may be broader or more conspicuous [ 5 , 6 ]. Keloid susceptibility is reported to be higher in some Asian populations and is influenced by genetic factors, including evidence from Malay cohorts [ 7 , 8 , 36 ]. Pigmentary response and prolonged erythema can also increase scar conspicuity in darker skin types, contributing to greater perceived scar burden [ 36 ]. CROMs are structured tools used by healthcare professionals to evaluate clinical features based on observation and examination. In scar assessment, CROMs allow systematic rating of features such as pigmentation, vascularity, thickness or height, pliability or firmness, surface texture, and surface area [ 10 ]. Commonly used scales include POSAS and the Vancouver Scar Scale (VSS) [ 10 , 37 , 38 , 39 ]. POSAS (version 2.0) integrates observer and patient perspectives; the Observer Scale rates six scar characteristics (vascularity, pigmentation, thickness, relief, pliability, and surface area) on a 10‐point scale alongside an overall opinion item, supporting comprehensive traumatic scar evaluation when paired with patient input [ 37 ]. In contrast, the VSS evaluates four domains and was originally developed for burn scars, and it does not explicitly incorporate patient‐reported symptoms or experience, which may limit its scope for traumatic scars [ 10 , 38 ]. An administration tool with inter‐rater reliability for VSS scoring was described by [ 39 ]. 4.1. Limitation Several limitations should be considered when interpreting the present findings. First, the sample size, while acceptable for preliminary psychometric testing, was modest and largely comprised patients with soft tissue injuries, mainly following road traffic accidents. This case mix may limit the generalisability of the results to other scar populations, including post burn scars and larger postsurgical scars, and may also reduce the stability and replicability of the factor solution. Second, test–retest reliability was assessed over a two‐week interval, which supports short term stability but does not fully address longer term stability of the instrument. Future multicentre studies with larger and more heterogeneous samples, including hypertrophic, keloid, and post burn scars, are recommended to confirm the factor structure using confirmatory factor analysis, evaluate measurement invariance across relevant subgroups, and determine responsiveness to clinical change over time. 5. Conclusion In summary, the Malay version of the POSAS 3.0 demonstrated strong reliability, excellent content validity and acceptable construct validity. These findings support its use as a culturally appropriate and clinically relevant instrument for scar assessment in Malay‐speaking populations. The validated tool will facilitate consistent clinical evaluation and enhance research aimed at improving scar management and patient outcomes. Funding The authors have nothing to report. Ethics Statement This study received ethical approval from the Research Ethics Committee, The National University of Malaysia (UKM PPI/111/8/JEP‐2023‐414) and was carried out in accordance with the Helsinki Declaration. Conflicts of Interest The authors declare no conflicts of interest. Supporting information Table S1: Content of translated Malay POSAS 3.0 items (Patient and Observer Scales). IWJ-23-e70917-s001.docx (37.9KB, docx) Acknowledgements The authors would like to thank the patients and volunteers for their participation in this study. Data Availability Statement The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. References 1. Mekeres G. 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Supplementary Materials Table S1: Content of translated Malay POSAS 3.0 items (Patient and Observer Scales). IWJ-23-e70917-s001.docx (37.9KB, docx) Data Availability Statement The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. 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