Introduction
The Korean population in the USA is expanding beyond traditional urban centers, driven in part by significant investments from Korean companies [1,2]. However, despite this growth, Korean immigrants face substantial healthcare access barriers, primarily due to a high rate of English language barriers [3-5]. While major urban areas offer resources such as Korean-speaking doctors, clinics, and professional medical translators, rural areas, particularly in the South, struggle to provide similar support. For instance, Lee County, Alabama, a rural region, has seen a growing population of Korean immigrants with English barriers [6]. With over 20 Koreanowned auto suppliers, Lee County now has the second-largest Korean population in Alabama, representing approximately 12,622 Koreans (9%) of its total 140,247 residents [6]. Despite this significant presence, these immigrants face considerable challenges in accessing healthcare, including language barriers and a lack of culturally and linguistically appropriate resources, especially in hearing healthcare.
Hearing health is emerging as a global concern, with the increasing prevalence of hearing loss significantly impacting individuals’ quality of life and daily functioning. The effects of hearing loss extend beyond perceived hearing impairment and communication difficulties due to its association with other chronic health and psychosocial health status [7-9]. In South Korea, hearing loss affects an estimated 22.73% of the population, with older individuals and males disproportionately impacted. Specifically, unilateral hearing loss accounts for 9.31%, while bilateral hearing loss is reported at 13.42% of the overall population [10]. Despite its importance, addressing hearing loss within the Korean population in the USA is challenging due to language barriers and the absence of culturally and linguistically tailored tools that can capture the specific needs of this group. Developing globally applicable hearing healthcare tools is essential for ensuring equitable care across diverse populations. These tools, however, should be designed to address hearing loss from a multidimensional perspective, incorporating not only auditory impairment but also the broader impacts on communication, social participation, and overall well-being, as recommended by the Committee on Accessible and Affordable Health Care for Adults [11].
Traditionally, hearing healthcare services have focused on a unidimensional understanding of patients’ needs [12-14]. Currently, there is a shift toward recognizing hearing-related outcomes, such as hearing impairment and communication and conversation disability, through a more comprehensive lens, known as a biopsychosocial approach [14,15]. This approach is supported by the International Classification of Functioning, Disability and Health (ICF) and the ICF Core Sets (Brief and Comprehensive) for Hearing Loss, which provide a foundation for a multidimensional view of audiological rehabilitation [14-19]. While the Brief Core Set provides a minimum standard, the Comprehensive Core Set is meant for multiprofessional comprehensive assessment [17]. Therefore, interest in developing ICF-based instruments is increasing. Table 1 presents existing ICF-based instruments designed to assess individual needs in audiological rehabilitation from a multidimensional perspective [20-26].
The HEAR-COMMAND Tool, a self-rated, ICF-based questionnaire designed to assess hearing, communication, and conversation disability [23,24] is one of these instruments. To enhance access of the Korean population to hearing healthcare services while considering the current shift, this study translated the HEAR-COMMAND Tool–English into Korean. It also aimed to culturally adapt the tool and evaluate its comprehensibility, readability, and relevance among Korean individuals, regardless of hearing status.
Subjects and Methods
Participants
Participants were recruited from a Korean online community in Lee County, AL. Flyers written in both Korean and English were posted in the online chat group, and interested individuals voluntarily contacted the team. Any Korean immigrant living in Lee County, AL, who was born in Korea, fluent in Korean, and over 18 years old was eligible for the study. A total of 15 participants were enrolled in the study, conducted in two rounds from August to December 2024. Participants’ names and email addresses were collected through a one-to-one online chat app, “KaKao Talk”, and they were provided with an information letter, a consent form, a feedback form, and the translated tool via email. Feedback was collected within two weeks following each round, and participants were offered a $20 gift card as an incentive. The participants were between 18 and 60 (7 males and 8 females), with approximately 47% falling within the 46–60 age range. A significant portion (80%) held higher education degrees (bachelor’s, master’s, and PhD). Table 2 presents detailed information on the participants’ age and education levels.
Materials: The HEAR-COMMAND Tool
The HEAR-COMMAND Tool–English includes 120 items: 90 designed to assess functioning and 30 focused on demographic details, hearing status, and personal factors (Supplementary Materials 1 in the online-only Data Supplement). The tool covers 85% of the categories outlined in the brief ICF Core Sets for Hearing Loss, excluding the “Body Structures” domain. Furthermore, it addresses 44% of the comprehensive ICF Core Sets for Hearing Loss, including 73% of the Body Functions, 55% of the Activities and Participation, and 27% of the Environmental Factors domains.
The development of this tool was a collaborative effort across multiple countries, including Germany, the USA, the Netherlands, and Egypt. As a result, versions are available in English, German, and Arabic, making the tool applicable in various linguistic and cultural contexts [23,24]. Previous studies have demonstrated the tool’s high content and construct validity, proving its effectiveness in capturing patients’ perspectives on hearing loss and hearing-related functioning [23,24]. Additionally, it has shown the potential to improve treatment plans and audiologic rehabilitation by offering a comprehensive overview of daily hearing difficulties and their impact on patients’ quality of life [23,24].
Response interpolation
Item categorization
To interpolate the HEAR-COMMAND Tool results, the 90 ICF-based items are divided into four categories: 1) Items H.42 to H.48: These items assess the “voice and speech production functions.” They are required if the participant responds “yes” to item H41 (having health conditions causing speech impairment). For instance, conditions such as stroke can result in speech impairment, directly affecting an individual’s communication ability. 2) Items H.87 to H.90: These items correspond to “hearing aid benefits” and are required exclusively for participants who are hearing aid users. The remaining 78 items are classified into two categories based on performing exploratory factor analysis on the response of 215 participants [24]. 3) Hearing-related (audiological) items are further classified into three groups based on exploratory factor analysis conducted on the responses of 215 participants. “Auditory Processing Functionality” items: H18, H19, H21 to H35, H38, H39, and H73 (labeled “A”); “Sound Quality Compatibility” items: H83 to 86 (labeled “C”); “Listening and Communication Functionality” items: H36, H37, H40, H57, H62, H67 to H72, H74, and H82 (labeled “E”). 4) Non-hearing-related (non-audiological) items are further classified into four groups: “Interpersonal Interaction Functionality and Infrastructure Accessibility” items: H7, H49 to H56, H58 to H61, H63 to H66, and H81 (labeled “B”); “Social Determinants and Infrastructure Compatibility” items: H75 to H80 (labeled “D”); “Other Sensory Integration Functionality” items: H8 to H15 and H20 (labeled “F”); and “Cognitive Functionality” items: H1 to H6 and H16, H17 (labeled “G”).
Outcome scores
Based on the above classification, three outcome scores are defined for this tool: 1) Hearing-related score, including the items labeled A, C, and E (a total of 37 items); 2) Speech-perception score, encompassing the same labels as the hearing-related score, excluding the items not related to speech comprehension (total of 32 items); and 3) Non-hearing-related score, including the items labeled B, D, F, and G (a total of 41 items).
As the responses to each item are rated on a Likert scale ranging from 0 to 4, the overall response for each participant within a specific score is calculated as the sum of the responses to the corresponding items. To facilitate interpretation and enhance the comprehensibility of the scores for both participants and research conductors or healthcare providers, the raw summation scores are normalized and expressed on a scale from 0 to 10. For example, if a participant responds with 0 to all items within labels A, C, and E, the hearing-related score will be zero.
Disability degree classification
The developers of the HEAR-COMMAND Tool proposed a methodology to define the degree of self-reported disability based on the normalized outcome scores. It is important to note that the distribution of responses within the population sample directly influences the proposed threshold values. Accordingly, the current classification of disability degree is derived exclusively from the outcome scores of 215 participants, comprising individuals with normal hearing as well as those with mild to moderately severe hearing loss, including hearing aid users. For each outcome score, the degree of disability is classified separately and categorized into four levels: no, mild, moderate, and severe disability. The following example illustrates the threshold ranges applied for classification: no disability: 0≤ score <0.7; mild disability: 0.7≤ score <2.5; moderate disability: 2.5≤ score <4.3; and severe disability: score ≥4.3. For detailed information regarding the scoring procedure and disability classification, refer to [24].
Translation and creation of the HEAR-COMMAND Tool–Korean
The Korean version was developed using a rigorous six-step methodology to ensure linguistic accuracy, cultural relevance, and conceptual equivalence. This process was adapted from the WHO guidelines for translating the Disability Assessment Schedule 2.0 (WHODAS 2.0), as outlined in its Translation Package [27], and a practical guideline for novice researchers [28,29].
Step 1: Preparation
The translation process was organized systematically, providing translators with essential background information about the tool, including its purpose and intended applications.
Step 2: Forward translation
Forward translation was carried out by two native Korean speakers specializing in nursing. It relied on a decentered process that considered both source and target languages equally important and faithful to meanings and multiple perspectives.
Step 3: Synthesis of translation (cross-checking the forward translation)
The initial translated version was independently reviewed by a Korean-English language expert and a speech, language, and hearing sciences faculty member to verify that the translated text accurately reflects the meaning of the original content, linguistic accuracy, and cultural relevance.
Step 4: Harmonization
The Korean healthcare authors (HS, JH, and SK) further discussed the translations, resolving any discrepancies to create a pilot version of the HEAR-COMMAND Tool–Korean.
Steps 5 & 6: Pre-testing, feedback, and refinements
The translated tool was then tested with 10 Korean-speaking participants using a structured feedback questionnaire, leading to further refinement of the translated version. An additional five Korean American individuals then evaluated the revised version, resulting in the beta version of the HEARCOMMAND Tool–Korean.
The Feedback Questionnaire (Supplementary Materials 2 in the online-only Data Supplement) is designed to gather valuable insights from participants regarding their experiences with a specific tool related to hearing health and effective communication. It is divided into six sections, beginning with demographics, which collects information on age, education level, and native language. The second section focuses on readability, assessing how easy it was for respondents to understand the questions, using a Likert scale from 1 (very difficult) to 5 (very easy) to gauge their responses. Participants are also asked to evaluate the structure of the questions on a similar scale, ranging from 1 (very complex) to 5 (very simple), and to provide feedback on the layout’s helpfulness. The difficulty section evaluates the challenge level of the content, with responses ranging from 1 (very difficult) to 5 (very easy), and whether prior knowledge was assumed. Engagement is measured in the fourth section, where participants reflect on how captivating they found the tool using a scale from 1 (not engaging at all) to 5 (extremely engaging) and whether it held their attention throughout. The fifth section assesses the real-world relevance of the content. Respondents rate how applicable they find the questionnaire on a scale from 1 (not applicable at all) to 5 (extremely applicable). They also specify their likelihood of visiting a related clinic for hearing and communication issues, using a scale from 1 (definitely not) to 5 (definitely yes). Finally, the additional feedback section invites open-ended comments and suggestions for improvement, ensuring that participants can provide comprehensive feedback on their experiences.
Results
The HEAR-COMMAND Tool–Korean, consisting of 120 items, took approximately 15 to 20 minutes to complete. Ten of the 15 participants found the items either easy or very easy to understand. However, concerns were raised regarding sentence structure and specific word choices. As a result, the questionnaire was rated as moderately difficult, with some concepts perceived as particularly challenging. In addition, 10 participants noted difficulties with certain aspects, especially for those without prior knowledge of hearing loss or communication disabilities. The most difficult questions were reported as follows: H01. Do you have problems with mood (e.g., experience intense mood swings [shifts] and self-image issues, rapid issues in mood in a relatively short period of time)?; H17. Do you have a problem with producing (vocalizing) a meaningful message in your language?; H22. Do you have a problem with distinguishing the tone of sounds in general?; H62. Do you have difficulty with speech reading (lip-reading)? Participants emphasized the need to simplify technical terminology, particularly for terms such as “lip reading,” “tone of sounds,” and “self-image,” to enhance accessibility. Participants also identified cultural and linguistic concerns with the phrase “paid employment,” the term “barrier,” and the word “you.”
All 15 participants rated the tool as moderately to highly engaging, with 10 specifically stating that it successfully held their attention from start to finish. Finally, 11 participants considered the tool applicable to their everyday functioning, and, notably, 14 out of 15 participants indicated that the tool would likely motivate them to seek professional help for hearing concerns. However, participants suggested incorporating electronic formats for easier accessibility.
Questionnaire revised version
The Korean experts refined the questionnaire by incorporating respondent feedback and adjusting the terminology of items. To ensure a precise interpretation of technical terms, two main types of revisions were implemented. First, they modified the wording for clarity by rephrasing questions with common Korean expressions, preserving the core English concepts while making them more accessible to the general Korean public. Second, they added clarifications by including examples or definitions, marked with an asterisk below questions, to explain professional or ambiguous terms and enhance understanding.
For example, in item H01, the original English question was revised by adapting “mood” to “mood and emotional control,” a more familiar phrasing in Korean, and an asterisk clarification was added: “Self-image issues: For example, negative perceptions of one’s physical appearance or low self-esteem.” This provides readers with a clearer grasp of the topic. In item H17, the original English question was simplified and specified for better comprehension to: “Do you have difficulty producing speech sounds during conversation?” For item H22, the phrase “tone of sounds” was elaborated with an asterisk: “Tone of sound: The qualities that distinguish a sound, such as pitch, loudness, and timbre.” Similarly, “speech reading (lipreading)” was defined as: “Speech reading (lip-reading): A technique for understanding spoken language through the speaker’s facial expressions, body language, hand gestures, and lip movements.”
In the cultural and linguistic adaptation process, the phrase “paid employment” was adjusted to “paid employee” to align with common usage, and the term “barrier” was replaced with “disturbance” in specific contexts to enhance understanding. The other example of a linguistic challenge was how the English word “you” has multiple possible translations in Korean. In Korean, the choice of word for “you” depends on the context, level of formality, and relationship between the speakers. Since Korean distinguishes between these different forms, translating English sentences containing “you” to Korean requires careful selection of the most appropriate wording to maintain clarity and cultural appropriateness. The beta version of the HEAR-COMMAND Tool–Korean is available as Supplementary Materials 3 (in the online-only Data Supplement).
Discussion
This study focused on translating and culturally adapting the HEAR-COMMAND Tool from English to Korean and assessing its comprehensibility, readability, and relevance among Korean individuals, regardless of their hearing functioning status. The ICF framework highlights that functioning is relevant to everyone, not just those with disabilities, making it essential for the tool to be inclusive and accessible to a diverse audience. The authors believe that translating and culturally adapting the HEAR-COMMAND Tool–Korean is a significant step toward meeting the healthcare needs of Korean immigrants in the USA, particularly those facing language barriers, as well as Korean individuals requiring hearing assessments. Grounded in the ICF framework, this tool enhances hearing-related evaluations by providing a standardized, culturally appropriate assessment. Its development not only improves access to care for Korean-speaking individuals in the USA but also has global implications, enabling healthcare professionals to conduct more accurate and comprehensive evaluations.
The overall results demonstrate that the HEAR-COMMAND Tool–Korean is feasible, comprehensible, readable, and relevant to Korean individuals, regardless of their hearing functioning status. The time taken to complete the questionnaire aligns with findings from the previous study [24]. The feedback from participants revealed several areas for improvement, particularly in terms of linguistic naturalness, cultural relevance, and accessibility. These findings align with previous research emphasizing the need for culturally sensitive healthcare tools that account for the unique linguistic and cultural contexts of immigrant populations [27-29].
The overall difficulty was rated as moderate, with certain concepts being particularly challenging, especially for those unfamiliar with hearing loss or communication disabilities. Specifically, questions related to mood regulation (H01), message vocalization (H17), tone differentiation (H22), and speech reading (H62) were difficult to comprehend. These issues align with findings from other translation studies, which stress the importance of linguistic precision and cultural nuance in effective translated tools [20-26]. For example, the difficulty of understanding the question related to mood regulation (H01), which is relative to the ICF category b126 Temperament and personality functions, has been established in previous validation studies, including the validation of the Brief ICF Core Set for Hearing Loss [20-26]. The revisions to the HEAR-COMMAND Tool–Korean, including simplifying technical terms and adding definitions, address these concerns and enhance the tool’s accessibility.
Another linguistic and cultural challenge involved rewording to enhance clarity and align with Korean language conventions. Some items required greater specificity, while others needed stylistic adjustments to better reflect Korean cultural norms. For example, “paid employment” was revised to “paid employee,” and “barrier,” though consistent with ICF terminology [15], was replaced with “disturbance” to improve cultural appropriateness. Additionally, the translation of “you” into the Korean language necessitates careful consideration, as Korean offers multiple pronouns and speech levels depending on formality and social hierarchy.
Moreover, participants found the tool moderately to highly engaging, indicating its potential to capture the target audience’s attention and interest. To enhance its effectiveness, they suggested developing an online or digital version of the tool. This highlights the need for innovative approaches to improve accessibility, particularly for individuals with hearing impairments who may benefit from digital formats. This initiative is currently underway, and the online platform hosting the tool is anticipated to seamlessly integrate these translations, ensuring that individuals from different language backgrounds can benefit from a standardized and comprehensive assessment of hearing health-related factors [22].
Finally, although the readability and potential application of the HEAR-COMMAND Tool–Korean were evaluated with satisfactory results, and revisions were made to improve the clarity of highlighted items, the next step is to conduct psychometric testing. This phase will assess the tool’s content validity, construct validity, criterion validity, reliability, and responsiveness among Korean individuals with varying degrees of hearing loss, ensuring its robustness and effectiveness in clinical practice.
A notable finding was that 14 out of 15 participants indicated that the HEAR-COMMAND Tool–Korean would likely motivate them to seek professional help for hearing concerns. This suggests that the tool not only serves as an assessment instrument but also has the potential to act as a catalyst for healthcare-seeking behavior. This is particularly considerable given the barriers to healthcare access faced by Korean immigrants, including language difficulties and a lack of culturally appropriate resources. By addressing these barriers, the HEAR-COMMAND Tool–Korean can play a vital role in promoting hearing health awareness and encouraging timely intervention.
Implications for clinical practice and policy
The development of the HEAR-COMMAND Tool–Korean represents a crucial advancement that benefits both the Korean-speaking community and the healthcare professionals serving them. By integrating culturally adapted and linguistically appropriate tools, audiologists and healthcare providers can enhance communication, improve healthcare accessibility, and deliver more effective, patient-centered care. These efforts are particularly vital for immigrant communities, such as those in Lee County, Alabama, where language barriers may limit access to essential healthcare services. For example, the implementation of culturally adapted tools can contribute to the earlier identification of hearing and other health concerns, leading to improved outcomes in underserved communities. On a broader scale, the increased adoption of such resources may shape healthcare policies by reinforcing the need for cultural competence in clinical settings. This shift could ultimately drive systemic improvements that promote greater healthcare equity and inclusion.
Additionally, the tool’s structured item categorization and standardized scoring system provide a data-driven framework for assessing both hearing-related and non-hearing-related challenges. By incorporating functional classifications—such as auditory processing, sound quality compatibility, and listening and communication functionality—the tool ensures a comprehensive evaluation that aligns with the diverse needs of individuals. This approach enhances clinical decision-making and supports the development of targeted interventions that address specific communication barriers.
Moreover, the HEAR-COMMAND Tool’s disability classification system, which categorizes individuals into no, mild, moderate, or severe disability levels, provides a standardized measure for assessing communication difficulties. This framework is instrumental in shaping healthcare policies by promoting equitable resource allocation, advocating for evidencebased rehabilitation strategies, and emphasizing the importance of culturally and linguistically appropriate assessments in clinical practice.
Future research should prioritize further validation of the HEAR-COMMAND Tool and investigate its impact in both clinical and community settings. Expanding validation efforts across diverse populations will strengthen its reliability and applicability, while examining its real-world implementation can provide valuable insights into its effectiveness in improving healthcare access, communication, and patient outcomes.
Strengths and limitations
A key strength of this study is its systematic, multi-step approach to translation and cultural adaptation, ensuring the rigor of the HEAR-COMMAND Tool–Korean before assessing its content validity. This process distinguishes translation-related findings from broader issues concerning the questionnaire’s validity. The involvement of bilingual experts and native Korean speakers, along with iterative feedback from Korean community participants, enhanced the tool’s linguistic accuracy and cultural relevance. Despite the rigorous translation and cultural adaptation process, this study has some limitations. The sample size, while informative, may not fully capture the diversity of the Korean-speaking population, necessitating further research with larger and more varied groups. Additionally, the reliance on self-reported data may introduce response bias, and subtle nuances in translation could still affect interpretation. To address these limitations, a cognitive interview using a combined deductive and inductive approach should be conducted to refine the tool further and ensure its clarity and cultural appropriateness [30].
Conclusion
The translation and cultural adaptation of the HEAR-COMMAND Tool into Korean represent a significant advancement in addressing the hearing healthcare needs of Korean-speaking individuals worldwide. The HEAR-COMMAND Tool–Korean demonstrates high levels of comprehensibility, readability, and cultural relevance, making it a valuable resource for improving access to hearing healthcare in this underserved population. By addressing linguistic and cultural barriers, the tool has the potential to enhance healthcare-seeking behavior and promote better hearing health outcomes among Korean immigrants. Future research should focus on further validating the tool and exploring its impact in clinical and community settings.
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