German translation and cultural adaptation of the Hearing Environments and Reflection on Quality of Life (HEAR-QL26) questionnaire for children aged 7 to 12 years

Purpose: This study aimed to translate and culturally adapt the Hearing Environments and Reflection on Quality of Life (HEAR-QL26) questionnaire into German for children aged 7 to 12 years with hearing loss. The objective was to ensure semantic, conceptual, and cultural equivalence and to provide a valid tool for assessing hearing-related quality of life in this population. Method: The adaptation followed international guidelines for cross-cultural translation of hearing-related instruments. The process included: (1) preparation, (2) forward translation by independent translators, (3) reconciliation, (4) back translation, (5) expert committee review, and (6) field testing through cognitive interviews. Feedback was used to refine the questionnaire, and all revisions were subjected to back translation and expert review until consensus was reached. Results: The process revealed challenges in achieving full semantic equivalence, particularly for terms without direct German equivalents. Initial testing with ten children showed that several items were difficult to understand, leading to simplification of wording, merging of redundant items, and removal of complex comparisons. A revised version was subsequently tested with a total of 14 children, comprising the original ten children and four additional participants, confirming improved clarity and appropriateness. The final German version of the HEAR-QL comprises 25 items in plain language, with strong conceptual alignment to the original instrument. Conclusions: The study demonstrates the feasibility and challenges of adapting a complex pediatric quality of life questionnaire into another language and cultural context. While the German HEAR-QL25 retained fidelity to the original, certain semantic nuances could not be fully preserved, and the small, homogeneous sample limited generalizability. Despite certain semantic limitations and a small, homogeneous sample, the adapted version offers a promising tool for assessing hearing-related quality of life in German-speaking children. Further validation in larger and more diverse populations is recommended.