International Journal of Audiology 2015; 54: 341–346
Original Article
Cross-cultural adaptation of an Arabic version of the 10-item hearing handicap inventory Barbara E. Weinstein*, Doha Rasheedy†, Hend M. Taha† & Fathy N. Fatouh‡ *Doctor of Audiology Program, Graduate Center, CUNY, New York, USA, †Geriatrics and Gerontology Department; Faculty of Medicine, Ain Shams University, Cairo, Egypt, and ‡Doctor of Audiology, ENT Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Abstract Objective: The purpose of this study was to translate and culturally adapt an Arabic version of the hearing handicap inventory for the elderly - screening (HHIE-S). Design: The HHIE-S was translated following cross-cultural adaptation guidelines, and pretested in 20 elderly patients with hearing impairment. Next, the adapted Arabic HHIE-S underwent psychometric evaluation. The results were confirmed by pure-tone audiometer (PTA) examination. The patients completed the HHIE-S again after one hour. The validation of the questionnaire using Cronbach’s alpha (internal consistency), (construct validity), and intraclass correlation coefficients (repeatability) was performed. Study sample: Twenty elderly subjects with hearing impairment were recruited for the pretesting stage, and 100 elderly subjects were recruited for the psychometric evaluation stage. Patients with acute illness, functional dependency, cognitive impairment, and previous users of hearing aids were excluded. Results: The adapted Arabic HHIE-S showed good internal consistency (α ⫽ 0.902). Construct validity was good, as high correlations were found between the scale and the PTA outcome (r ⫽ 0.688, p ⫽ 0.000). Repeatability was high (ICC ⫽ 0.986). Conclusions: This study showed that the adapted Arabic HHIE-S is a valid and reliable questionnaire for the assessment of handicapping hearing impairment in Egyptian elderly patients.
Key Words: Hearing loss; hearing handicap inventory; validation; reliability
Hearing loss is the third most common chronic condition affecting the elderly (Lethbridge-Cejku et al, 2004); however, it is usually under-recognized and under-reported because patients may be unaware of their condition or unwilling to admit having a problem (Cruickshanks et al, 1998). Hearing loss has a major impact on psychological and social well-being (Dalton et al, 2003) because it affects nearly all aspects of everyday life. It interferes with solitary activities, such as listening to the television or radio, leading to impaired psychological wellbeing. Moreover, difficulty in using the telephone may compromise patients’ safety and security (Milstein & Weinstein, 2003). The increasing difficulty in recognition of the spoken messages of others, the need for frequent repetition, and uncertainty about having understood correctly, often lead to withdrawal from social activities, such as diminished attendance at social gathering in theatres, cinemas, churches, lectures, etc. This, in turn, leads to reduced intellectual and cultural stimulation (Arlinger, 2003). Therefore, hearing loss can lead to social isolation, depression, anxiety, poor quality of life (QoL), and even cognitive decline in the elderly population (Ciorba et al, 2012).
In order to prevent these negative consequences, clinicians should attempt early recognition of hearing impairment as an integral part of the comprehensive geriatric assessment. The gold standard method for clinical detection of hearing loss is the audiogram; however, problems regarding access, referral, and reimbursement may restrict its use. Therefore, self-administered questionnaires are widely used as a quick and inexpensive method to screen for hearing loss in clinical settings (Gates et al, 2003). Several questionnaires for assessing hearing disability have been developed and used by the English-speaking countries such as the hearing disability and handicap scale (HDHS) (Hetu et al, 1994), and the Gothenburg profile (GP) (Ringdahl et al, 1998). In 1982, Ventry and Weinstein introduced the 25-item hearing handicap inventory for the elderly (HHIE), to assess the selfperceived psychosocial handicap of hearing impairment in the elderly (Ventry & Weinstein, 1982). A shorter widely used 10-item version of the HHIE, the hearing handicap inventory for the elderly - screening (HHIE-S), was introduced in 1986 as a screening tool for handicapping hearing loss. This instrument consists of 10 questions designed to
Correspondence: Doha Rasheedy, MD, Geriatrics and Gerontology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt. E-mail: [email protected] (Received 6 April 2014; accepted 22 November 2014 ) ISSN 1499-2027 print/ISSN 1708-8186 online © 2015 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society DOI: 10.3109/14992027.2014.996827
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Abbreviations HHIE-S Hearing handicap inventory for the elderly - screening ICC Intraclass correlation coefficient PTA Pure-tone audiometer ROC Receiver operating characteristic
assess perceived emotional and social problems related to impaired hearing (e.g. frustration, embarrassment, or difficulty in certain situations). One of three responses (‘yes’, ‘sometimes’, or ‘no’) was recorded for each question and scored as 4, 2, or 0, respectively (Weinstein, 1986). The HHIE and its short form are of the most widely used instruments in English-speaking countries. They are also available in many languages, including Spanish (Lichtenstein & Hazuda, 1998), Brazilian Portuguese (Aiello et al, 2011), Italian (Monzani et al, 2007), Japanese (Sato et al, 2004), and Chinese (Jupiter & Palagonia, 2001). Although, Arabic is the fourth most commonly spoken language in the world and there are an estimated 221 million native Arabic speakers, who comprise 3.7% of the world’s population (Lewis, 2009), the HHIE and its short form, as well as many other screening questionnaires, lack sufficient validity for the Arabic speaking elderly, which limits their use in clinical and research settings. The aim of the present study was to cross-culturally adapt an Arabic version of the HHIE-S, and to validate the produced Arabic version in elderly Egyptians patients with hearing loss. The study methodology was reviewed and approved by the Research Review Board of the Geriatrics and Gerontology Department, Faculty of Medicine, Ain Shams University. Informed consent was taken from every subject participating in this study. The permission from the author was obtained, then the translation and cultural adaptation of the 10-item hearing handicap inventory for the elderly - screening questionnaire (HHIE-S) was produced by following the stages proposed by Beaton et al, 2000.
Stage 1: Translation of the 10-item HHIE-S Two initial forward translations of HHIE-S into Arabic were obtained by two bilingual translators whose mother tongue is Arabic. Then researchers approved an Arabic version using the original questionnaire as well as both translations. Later, back translation of the approved Arabic version into English was performed. The back-translator was a certified translator, native speaker of Arabic, and proficient in English. He was blinded to the original version of HHIE-S. The researchers reviewed all translations and the original questionnaire to reach consensus on any discrepancies and to produce a preliminary version for field testing.
Stage 2: Cultural adaptation of the Arabic (HHIE-S) and pretesting of the adapted form Three culturally appropriate equivalents were added to the Arabic HHIE-S to facilitate its use in elderly Egyptians. Two of the situational items in the original questionnaire referred to activities which were not commonly practiced by Egyptian elderly populations, such as outdoor dining and attending religious services.
So, the authors replaced them by two more culturally appropriate items from the original 25-item hearing handicap inventory (using the telephone and shopping). The third replaced item was the emotional item of feeling embarrassed when meeting new people. It was replaced by another emotional item (being upset by the hearing problem) because most of the Egyptian elderly prefer indoor activities and have a minimal chance of meeting new people. The final Arabic HHIE-S and suggested authors’ modifications were tested in a face to face interview of 20 elderly subjects with hearing impairment, randomly selected at the Audiology Unit in Ain Shams University Hospital. Their hearing loss was documented by pure-tone audiometry. To test for face validity and content validity, the respondents were probed for their understanding, acceptability, and the emotional impact of each item in order to detect confusing or misleading items. The respondents were asked to rephrase each item in their own way to identify whether an item was understood or not. Moreover, they were asked if they were accustomed to performing these activities.
Results of pretesting stage The mean age of the 20 subjects included in the pretest was 66.8 ⫾ 3.4 years; 60% of the participants were males and 40% were females. Ten of the participants were illiterate; four of them had less than five years of education, another five finished secondary school, and only one had college education. Minor modifications were made according to participants’ suggestions in items number 2 and 6. Three of the participants suggested replacing the word ‘frustrated’ by the word ‘upset’ in item 2. Four subjects suggested changing the phrase ‘attendance to religious ceremonies’ to ‘praying in congregation at the mosque or the church’ in item 6. The remaining items were fully understood and accepted by the patients; however, many subjects were not accustomed to performing the activities of meeting new people, attending religious ceremonies, or being in a restaurant. The patients’ responses are shown in Table 1.
Stage 3: The psychometric evaluation of the modified Arabic (HHIE-S) A new group of 100 consecutive subjects were recruited from the Geriatric Medicine Unit in Ain Shams University Hospital. Only those who consented were recruited to the study. All subjects were 60 years or older, and were (1) functionally independent (activity of daily living (ADL) Score ⫽ 6 (Katz et al, 1963), and instrumental activity of daily living (IADL) Score ⫽ 8 (Lawton & Brody, 1969)); (2) not acutely-ill (they didn’t need medical supervision or specialized nursing care for any co morbid conditions); (3) without cognitive impairment that interfered with interviewing the patient (mini mental state examination score ⱖ 26 indicates normal cognitive function (Folstein et al, 1975)); and (4) without previous use of hearing aids. Initially, the subjects were given general instructions of the HHIE-S by the researcher. The Arabic initial and three adapted items after the pre-testing stage were administered either by pen or in face to face interview for illiterate subjects. The responses were scored 0 for a no response, 2 for a sometimes response, and 4 for a yes response. The total score was the sum of all responses. Subjects reported when they weren’t accustomed to performing the activity due to any other cause rather than hearing impairment.
Validated Arabic Hearing Handicap Inventory
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Table 1. Patients’ responses obtained during pretesting phase. Patient’s response Item 1 2 2# 3 4 5 6 6# 7 8 9 10 11* 12* 13*
No Do hearing problems embarrass you when you meet new people? Does a hearing problem make you feel frustrated when you talk to your family members? Does a hearing problem make you feel upset when you talk to your family members? Do you find it difficult when someone speaks in a whisper? Do you feel that you have a disability because of a hearing problem? Does a hearing problem cause you difficulty when visiting friends and relatives, or neighbors? Does a hearing problem reduce your attendance to religious ceremonies more than you would like? Does a hearing problem reduce your praying in congregation at the mosque or the church? Does a hearing problem cause disputes between you and a family member? Does a hearing problem cause difficulty when you are listening to the radio or television? Do you feel that any difficulty in hearing limits or hinders your personal or social life? Does a hearing problem cause you difficulty when you are in a restaurant with relatives or friends? Does a hearing problem reduce your shopping more than you would like? Does a hearing problem reduce your use of the telephone more than you would like? Does any problem or difficulty with your hearing upset you at all?
Sometimes
Yes
5% (1) 35% (7)
40% (8) 45% (9)
10% (2) 20% (4)
20% (4) 50% (10) 20% (4)
50% (10) 35% (7) 60% (12)
30% (6) 15% (3) 20% (4)
15% (3)
40% (8)
_
70% (14) 15% (3) 50% (10) 5% (1)
25% (5) 55% (11) 35% (7) 5% (1)
5% (1) 25% (5) 15% (3) 5% (1)
25% (5) 15% (3) 25% (5)
35% (7) 55% (11) 15% (3)
25% (5) 30% (6) 60% (12)
Not accustomed 45% (9) _ _ _
45% (9)
5% (1) 85% (17) 15% (3)
*Added equivalent items. # modified original items.
After the first administration was completed, all subjects underwent otoscopic examination and audiometric testing by an audiologist blinded to the HHIE-S results. One hour later, the subjects had the second administration of the adapted Arabic 10 item HHIE-S by another interviewer. The responses from two administrations were collected for data analysis.
Audiometric screening test Audiometric screening was used to determine the presence of any organic hearing impairment and to categorize its severity based on PTA of the better ear. PTA between 0–25 dB was considered within normal limits, PTA ⬎ 25 dB indicated mild hearing loss, PTA ⬎ 40 dB indicated moderate hearing loss, and PTA ⬎ 60 dB indicated severe hearing loss. Pure-tone testing was conducted in a double walled sound treated room I.A.C model 1602 using a standard two-channel audiometer Ineracoustics, model AC 40; calibrated according to ANSI S.3.6, 1996 and connected to TDH 39 headphones, bone vibrator B71 and two loudspeakers for quasi free sound field testing. Hearing thresholds were measured in each ear for frequencies 1000, 2000, and 3000 Hertz (Hz). Bone conduction was evaluated when the air conduction threshold was ⬎ 15 dB in any of the frequencies used.
Statistical analysis Descriptive data were presented as mean, and standard deviation. The Arabic HHIE-S questionnaire was tested for reliability and construct validity. Reliability is defined as the degree in which the measured result reflects the true result. In the present study, reliability was measured by assessing the internal consistency and the test-retest consistency. The internal consistency of the questionnaire was measured by the Cronbach’s alpha. It was helpful in deciding whether different questions in a questionnaire were measuring the same underlying
concept and whether each item of the questionnaire was a consistent indicator of hearing handicap. A Cronbach’s alpha coefficient of 0.70 was the minimally acceptable level for internal consistency reliability. Cronbach’s alpha was also calculated when each item was removed from the questionnaire to establish how each item affected the reliability of the instrument. Regarding the test-retest consistency, comparison was made by calculating a Spearman’s correlation coefficient (rho) between the first and second administration of the questionnaire. We calculated intraclass correlation coefficients (ICCs) with corresponding 95% CIs for evaluating inter-rater reliability. ICCs above 0.70 were considered to be good repeatability Agreement between the adapted Arabic HHIE-S and audiometry was evaluated using Spearman’s correlations (rho) to establish construct validity of the questionnaire. The ROC curve was used to find the optimal cut-off point for detecting hearing impairment. Sensitivity, specificity, positive predictive value, and negative predictive values were calculated for possible cut off points. Statistical analysis was done on a personal computer using IBM© SPSS© Statistics version 16 (IBM Corp., Armonk, USA). A p-value of ⬍ 0.05 indicated statistical significance.
Results of psychometric evaluation of the adapted Arabic (HHIE-S) Among 100 patients enrolled in the study, 44% (n ⫽ 44) of the subjects tested positive using audiometry for hearing impairment. Seven percent (n ⫽ 7) had severe hearing impairment, 16% (n ⫽ 16) had moderate hearing impairment, and 21% (n ⫽ 21) had mild hearing impairment according to the pre-defined criteria. The remaining 56% (n ⫽ 56) had normal hearing. The mean HHIE-S scores were 29.7 ⫾ 6.36, 20.0 ⫾ 9.38, 9.8 ⫾ 6.13, and 3.5 ⫾ 2.86, respectively. The demographic data of the participants is shown in Table 2.
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Table 2. Demographic data of patients with and without hearing impairment.
Variable Age (years) Gender, n (%) Female Male
Without hearing loss impairment (n ⫽ 56)
With hearing loss impairment (n ⫽ 44)
68.32 ⫾ 6.80
66.47 ⫾ 6.02
22 (39.30%) 34 (60.70%)
20 (45.50%) 24 (54.50%)
P* 0.13 0.53
Table 3. Construct validity and reliability of the adapted Arabic HHIE-S. Construct validity
Reliability
Spearman correlations between the adapted Arabic (HHIE-S) item and audiometry results
The internal consistency of the adapted Arabic (HHIE-S)
Item Education, n (%) Illiterate (can’t read or write) Less than 5 years of education Secondary school College Living arrangement, n (%) Alone With spouse With offspring Social class, n (%) Low social class Middle social class High social class Arabic (HHIE-S) score (mean⫾ SD)
0.46 20 (35.70%)
16 (36.40%)
5 (8.90%)
2 (4.50%)
16 (28.60%) 15 (26.80%)
18 (40.90%) 8 (18.20%)
3 (5.40%) 36 (64.30%) 17 (30.40%)
2 (4.50%) 35 (74.50%) 7 (15.90%)
24 (42.90%) 32 (57.10%) 0 3.50 ⫾ 2.80
22 (50%) 21 (47.70%) 1 (2.30%) 16.60 ⫾ 10.40
0.22
0.37
0.00*
Values are mean ⫾ SD or n (%) independent t test, chi-square test where appropriate. *statistically significant.
According to subjects’ responses, it was reported that 18% of subjects were not accustomed to meeting new people, 50% did not attend religious ceremonies, 92% were not accustomed to outdoor dining, while only 3% did not visit acquaintances, and 8% were not used to shopping. To determine the construct validity, the total Arabic HHIE-S score and individual item scores were compared to PTA outcomes using Spearman’s correlation coefficients. It ranged between 0.35–0.67 for adapted Arabic HHIE-S items, and it was 0.68 for the total score. The significant correlations between each HHIE-S item, total score and PTA outcome suggested that the adapted Arabic HHIE-S had adequate construct validity (Table 3). Reliability in the form of internal consistency and test-retest reliability was assessed. Internal consistency refers to the extent to which items within the questionnaire are related to each other. The Cronbach’s coefficient alpha and item-total correlation coefficients were generated to examine the internal consistency of the HHIE-S (Table 3). In the current study, the Cronbach’s alpha is 0.902, which indicates a high level of internal consistency for the adapted Arabic HHIE-S. Observation of the item-total correlation revealed two low correlations: item 2 (r ⫽ 0.46) and item 3 (r ⫽ 0.38); yet, the two items were kept in the questionnaire because calculating α without item 2 (α ⫽ 0.869), and item 3 (α ⫽ 0.891) decreased the overall Cronbach’s alpha of the 10 items. Test-retest reliability assessed the degree to which the results were consistent over time and when rated by different interviewers. Mean scores and Spearman’s correlations of the test-retest are presented in
Q2 Q3 Q4 Q5 Q7 Q8 Q9 Q 11 Q 12 Q 13 Total score
r
P value
Item
0.64 0.51 0.57 0.35 0.51 0.42 0.53 0.61 0.41 0.67 0.68
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Q2 Q3 Q4 Q5 Q7 Q8 Q9 Q 11 Q 12 Q 13
Corrected item: Total correlation
Cronbach’s alpha (if item deleted)
0.46 0.38 0.86 0.59 0.71 0.61 0.81 0.58 0.80 0.87 Cronbach’s alpha:
0.869 0.891 0.878 0.896 0.893 0.896 0.883 0.897 0.882 0.879 0. 902
Construct validity confirmed by assessment of correlation between the adapted Arabic HHIE-S item and PTA using Spearman’s correlations, the internal consistency of the adapted Arabic HHIE-S using Cronbach’s Alpha.
Table 4. Test-retest correlations were sufficiently high for all items, suggesting good questionnaire stability over time (ranged from 0.82 for item 3 to 0.97 for total score). We calculated intraclass correlation coefficients (ICCs) with corresponding 95% CIs (ranged from 0.633 for item 5 to 0.986 for total score) which suggested a good agreement between different examiners (Table 4). The ROC curve was used to determine the degree to which the adapted Arabic HHIE-S could detect the degree of hearing loss (HL). The area under curve (AUC) was 0.945, 0.953, and 0.954 for predicting mild, moderate, and severe HL, respectively (Figure 1).
Table 4. Test re-test reliability descriptive statistics and repeatability measures of the Arabic HHIE-S. Mean score of the modified Arabic HHIE-S
Item Item 2: score Item 3: score Item 4: score Item 5: score Item 7: score Item 8: score Item 9: score Item 11: score Item 12: score Item 13: score Total score
First Second ICC administration administration Spearman’s r (95% CI) 1.28 ⫾ 1.49 2.70 ⫾ 1.56 0.68 ⫾ 1.39 0.44 ⫾ 1.04 0.38 ⫾ 0.88 0.76 ⫾ 1.35 0.58 ⫾ 1.21 0.56 ⫾ 1.10 1.20 ⫾ 1.40 0.72 ⫾ 1.28 9.30 ⫾ 9.43
1.3 ⫾ 1.48 2.50 ⫾ 1.52 0.66 ⫾ 1.36 0.4 ⫾ 1.02 0.44 ⫾ 0.96 0.78 ⫾ 1.33 0.56 ⫾ 1.24 0.56 ⫾ 1.10 1.30 ⫾ 1.48 0.76 ⫾ 1.29 9.30 ⫾ 9.74
0.98 0.82 0.95 0.86 0.92 0.95 0.94 1.00 0.94 0.96 0.97
0.99 0.85 0.96 0.63 0.86 0.95 0.96 0.95 0.93 0.97 0.98
ICCs: Intraclass correlation coefficients. CI: Confidence interval. ICCs above 0.70 were considered to be good repeatability.
Validated Arabic Hearing Handicap Inventory
Figure 1. Receiver operating characteristic (ROC) curve for using the adapted Arabic (HHIE-S) to predict hearing loss in elderly. The ROC curve shows that the adapted Arabic HHEI-S had an area under the curve of 0.945, 0.953, and 0.954 for predicting mild, moderate and severe HL, respectively. Based on the sensitivity and specificity of the different cut-off points of the adapted Arabic HHIE-S for detecting the severity of hearing loss, the score ⬎ 6 was useful in detecting mild hearing loss (The sensitivity and specificity were 84% and 67.8%, respectively). The sensitivity and specificity for detecting moderate HL were 83% and 87% respectively when the cut-off score was ⬎ 12. The score ⬎ 26 detected severe HL with 85.7% sensitivity and 94.6% specificity (Table 5).
Discussion Hearing impairment in the elderly can pass undetected because the elderly and their treating physician consider it a physiological aging Table 5. Summary of statistics of different scoring cut-off values of the modified Arabic HHIE-S predicting the degree of hearing loss as defined by pure-tone audiometry. Positive if greater than or equal to
Sensitivity
Specificity
Mild hearing loss (26–40 dB HL) 6 points 84.00% 67.80% 8 points 75.00% 87.50% 10 points 72.70% 98.20% 12 points 65.00% 100.00% Moderate hearing loss (41–59 dB HL) 12 points 83% 87% 14 points 78.20% 90.70% 16 points 73.90% 94.80% 20 points 65.20% 98.70% Severe hearing loss (⬎ 60 dB HL) 26 points 85.70% 94.60% 28 points 85.70% 94.60% 32 points 85.70% 96.70%
PPV
NPV
67.20% 82.50% 96.90% 100.00%
84.40% 81.60% 82.00% 78.80%
66.60% 72.00% 80.90% 93.70%
94.30% 93.20% 92.40% 90.40%
54.50% 60.00% 66.60%
98.80% 98.80% 98.90%
NPV: negative predictive value (percentage with a negative screening test who did not have hearing loss); PPV: positive predictive value (percentage with a positive screening test that had hearing loss).
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process. So, self-report scales may help those elderly with early diagnosis and severity detection of their hearing problem (Hidalgo et al, 2008). In this study, the reliability and validity of the adapted Arabic HHIE-S were examined, and its clinical utility for discriminating hearing impairment was proved using the ROC curve. In this study, to cross-culturally adapt the questionnaire, the items that were not practiced in the target culture were replaced by more suitable ones. Results showed that 18% of subjects were not accustomed to meeting new people, 50% did not attend religious ceremonies, and 92% were not accustomed to outdoor dining. Thus, telephone use and shopping were more suitable situational items, and feeling upset with hearing problem was a more suitable emotional item than feeling embarrassed when meeting new people. Although the HHIE-S was developed as a self-administered questionnaire, the low literacy rate among the subjects made them unable to complete the questionnaire by themselves, so we used a face to face interview to complete the questionnaire when required. The test-retest correlation for the total adapted Arabic (HHIE-S) score and each item score were significant (first administration: mean ⫽ 9.30, SD ⫽ 9.43; second administration: mean ⫽ 9.30; SD ⫽ 9.74; rho ⫽ 0.97, p ⬍ 0.001). This result suggested that the questionnaire had acceptable stability over time; however, the one hour interval between the two administrations may not be sufficient for test-retest reliability. The present study selected to retest in the same day in order to make it possible to keep track of the subjects. It was confirmed that the subjects did not memorize the first administration because some subjects did not repeat the same response on some items in the second administration. Our findings demonstrated that the HHIE-S adapted to the Arabic language maintained its original reliability and validity. The original English HHEI-S had internal consistency reliability (Cronbach’s alpha) of 0.87. Test-retest reliability was reported at 0.84 (P ⬍ 0.0001) (Weinstein, 1986). In the current study, the adapted Arabic HHEI-S showed good internal consistency (α ⫽ 0.902). Spearman’s correlation coefficients between the total score of the adapted Arabic HHIE-S and PTA confirmed a good construct validity of the questionnaire (rho ⫽ 0.688, p ⫽ 0.000). Repeatability of the questionnaire was high (ICC ⫽ 0.986). This data agreed with a study performed in Japan to validate HHEI-S. The reported Cronbach’s alpha coefficient was 0.91, Spearman’s coefficient of the total score was 0.90, and intra-class correlation coefficient was 0.85 (Tomioka et al, 2013). The lower Spearman’s correlation coefficients in our study may be attributed to a limitation of not conducting audiometric evaluation at frequencies above 3000 Hz, causing poorer correlation between HHEI-S score and PTA results; however, two previous validation studies were conducted similarly by comparing to audiometric thresholds at 1000/2000 Hz (Gates et al, 2003) or 1000/3000 Hz (Wu et al, 2004). However, the intra-class correlation coefficient was higher in the current study due to shorter time interval between the two administrations of the questionnaire. Regarding the discriminant validity, the adapted Arabic HHIE-S showed good ability to discriminate between patients with and without hearing impairment. The mean score was 16.6 ⫾ 10.4 vs. 3.5 ⫾ 2.8 respectively (p ⫽ 0.000). Moreover, the adapted Arabic HHIE-S was also capable of discriminating between different degrees of hearing loss. The mean HHIE-S scoring in the current study was 3.5 ⫾ 2.86, 9.8 ⫾ 6.13,
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20.0 ⫾ 9.38, and 29.7 ⫾ 6.36 for patients without hearing loss, with mild impairment, moderate impairment, and those with severe hearing loss, respectively. Therefore, it is strongly suggested that HHIE-S should be incorporated in the comprehensive geriatric assessment to screen for handicapping hearing impairment. According to Jupiter and DiStasio, the mean HHIE-S scoring was 3.7 ⫾ 4.9, 6.7 ⫾ 9.7, 14.0 ⫾ 10.5, and 20.5 ⫾ 8.8 for patients without hearing loss, with mild impairment, moderate impairment, and those with severe hearing loss, respectively (Jupiter & DiStasio, 1998). The prevalence of hearing loss detected by pure-tone audiometry in this study was 44% which is comparable to earlier studies. The prevalence of hearing loss was 39.4% among the elderly in the Blue Mountain Hearing Study (Sindhusake et al, 2001), and 36.9% in a study done among the elderly in Malaysia among subjects aged 55–99 years (Rosdina et al, 2010). Higher prevalence of hearing loss was observed in other studies (Deepthi & Kasthuri, 2012), where the prevalence of hearing loss was 72% among the Indian elderly population. The differences could be due to differences in the population studied, sample size and the pure-tone audiometry criteria used for diagnosing hearing loss.
Conclusions The results suggest that the Arabic HHIE-S is a reliable and valid screening tool for hearing loss suitable for use in clinical settings and research studies among the Egyptian elderly population.
Acknowledgements The authors would like to thank Ain Shams University Hospital for supporting this research. Declaration of interests: The authors declare no conflicts of interest with respect to the authorship or publication of this article. The authors received no financial support for the research or authorship of this article.
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Supplementary material available online Supplementary Appendix available online at http://informahealthcare.com/doi/abs/ 10.3109/14992027.2014.996827.
Folstein M., Folstein S. & McHugh P. 1975. Mini mental state. A practical method for gradient the cognitive state of patients for clinicians. Journal of Psychiatric Research, 12, 189–198. Gates G.A., Murphy M., Rees T.S. & Fraher A. 2003. Screening for handicapping hearing loss in the elderly. Journal of Family Practice, 52(01), 56–62. Hétu R., Getty L., Philibert L., Noble W.G. & Stephens D. 1994. Development of a clinical tool for the measurement of severity of hearing disabilities and handicaps. Journal of Speech-Language, Pathology, Audiology, 18, 83–95. Hidalgo J-L.T., Gras C.B., Lapeira J-M.T., Martínez I.P., López Verdejo M.A. et al. 2008. The Hearing-dependent daily activities scale to evaluate impact of hearing loss in older people. Ann Fam Med, 6, 441–447. Jupiter T. & DiStasio D. 1998. An evaluation of the HHIE-S as a screening tool for the elderly homebound population. JARA, 31, 11–21. Jupiter T. & Palagonia C.L. 2001. The hearing handicap inventory for the elderly screening version adapted for use with elderly Chinese American individuals. Am J Audiol, 10, 99–103. Katz S., Ford A.B., Moskowitz R.W., Jackson B.A. & Jaffe M.W. 1963. Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function, JAMA, 21(9), 185:914–919. Lawton M.P. & Brody E.M. 1969. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist, 9(3), 179–186. Lethbridge-Cejku M., Schiller J.S. & Bernadel L. 2004. Summary health statistics for U.S. adults: National Health Interview Survey, Vital Health Stat, 10, (222), 1–151. Lewis M.P (ed.). 2009. Ethnologue: Languages of the World, Sixteenth edition. Dallas, USA: SIL International. Online version: http://www. ethnologue.com/16. Lichtenstein M.J. & Hazuda H.P. 1998. Cross-cultural adaptation of the hearing handicap inventory for the elderly - screening version (HHIE-S) for use with Spanish-speaking Mexican Americans. J Am Geriatr Soc, 46(4), 492–498. Milstein D. & Weinstein B. E. 2003. Amplification: The treatment of choice for presbycusis. Geriatrics & Aging, 6(5), 19–21. Monzani D., Genovese E., Palma S., Rovatti V., Borgonzon M. et al. 2007. Measuring the psychosocial consequences of hearing loss in a working adult population: Focus on validity and reliability of the Italian translation of the hearing handicap inventory. Acta Otorhinolaryngologica Italica, 27,186–191. Ringdahl A., Eriksson-Mangold M. & Andersson G. 1998. Psychometric evaluation of the Gothenburg Profile for measurement of experienced hearing disability and handicap: Applications with new hearing-aid candidates and experienced hearing-aid users. Br J Audiol, 32(6), 375–385. Rosdina A.K., Leelavathi M., Zaitun A., Lee V.K.M., Azimah M.N. et al. 2010. Self-reported hearing loss among elderly Malaysians. Malaysian Family Physician, 5(2), 91–94. Sato M., Ogawa K., Inoue Y. & Masuda M. 2004. Adaptation of Japanese version of the hearing handicap inventory for adults (HHIA). Nihon Jibiinkoka Gakkai Kaiho, 107(5) 489–493. Sindhusake D., Mitchelle P. & Smith W. 2001. Validation of self-reported hearing loss. The Blue Mountain Hearing Study. Int J Epidemiol, 30(6), 1371–1378. Tomioka K., Ikeda H., Hanaie K., Morikawa M., Iwamoto J. et al. 2013. The hearing handicap inventory for elderly - screening (HHIE-S) versus a single question: Reliability, validity, and relations with quality of life measures in the elderly community, Japan Qual Life Res, 22(5), 1151–1159. Ventry I.M. & Weinstein B.E. 1982. The hearing handicap inventory for the elderly: A new tool. Ear Hear, 3 (3), 128–134. Weinstein B.E. 1986. Validity of a screening protocol for identifying elderly people with hearing problems. ASHA, 28(5), 41–45. Wu H.Y., Chin J.J. & Tong H.M.H. 2004. Screening for hearing impairment in a cohort of elderly patients attending a hospital geriatric medicine service. Singapore Med J, 45(2), 79–84.
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Original Article
Cross-cultural adaptation of an Arabic version of the 10-item hearing handicap inventory Barbara E. Weinstein*, Doha Rasheedy†, Hend M. Taha† & Fathy N. Fatouh‡ *Doctor of Audiology Program, Graduate Center, CUNY, New York, USA, †Geriatrics and Gerontology Department; Faculty of Medicine, Ain Shams University, Cairo, Egypt, and ‡Doctor of Audiology, ENT Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Abstract Objective: The purpose of this study was to translate and culturally adapt an Arabic version of the hearing handicap inventory for the elderly - screening (HHIE-S). Design: The HHIE-S was translated following cross-cultural adaptation guidelines, and pretested in 20 elderly patients with hearing impairment. Next, the adapted Arabic HHIE-S underwent psychometric evaluation. The results were confirmed by pure-tone audiometer (PTA) examination. The patients completed the HHIE-S again after one hour. The validation of the questionnaire using Cronbach’s alpha (internal consistency), (construct validity), and intraclass correlation coefficients (repeatability) was performed. Study sample: Twenty elderly subjects with hearing impairment were recruited for the pretesting stage, and 100 elderly subjects were recruited for the psychometric evaluation stage. Patients with acute illness, functional dependency, cognitive impairment, and previous users of hearing aids were excluded. Results: The adapted Arabic HHIE-S showed good internal consistency (α ⫽ 0.902). Construct validity was good, as high correlations were found between the scale and the PTA outcome (r ⫽ 0.688, p ⫽ 0.000). Repeatability was high (ICC ⫽ 0.986). Conclusions: This study showed that the adapted Arabic HHIE-S is a valid and reliable questionnaire for the assessment of handicapping hearing impairment in Egyptian elderly patients.
Key Words: Hearing loss; hearing handicap inventory; validation; reliability
Hearing loss is the third most common chronic condition affecting the elderly (Lethbridge-Cejku et al, 2004); however, it is usually under-recognized and under-reported because patients may be unaware of their condition or unwilling to admit having a problem (Cruickshanks et al, 1998). Hearing loss has a major impact on psychological and social well-being (Dalton et al, 2003) because it affects nearly all aspects of everyday life. It interferes with solitary activities, such as listening to the television or radio, leading to impaired psychological wellbeing. Moreover, difficulty in using the telephone may compromise patients’ safety and security (Milstein & Weinstein, 2003). The increasing difficulty in recognition of the spoken messages of others, the need for frequent repetition, and uncertainty about having understood correctly, often lead to withdrawal from social activities, such as diminished attendance at social gathering in theatres, cinemas, churches, lectures, etc. This, in turn, leads to reduced intellectual and cultural stimulation (Arlinger, 2003). Therefore, hearing loss can lead to social isolation, depression, anxiety, poor quality of life (QoL), and even cognitive decline in the elderly population (Ciorba et al, 2012).
In order to prevent these negative consequences, clinicians should attempt early recognition of hearing impairment as an integral part of the comprehensive geriatric assessment. The gold standard method for clinical detection of hearing loss is the audiogram; however, problems regarding access, referral, and reimbursement may restrict its use. Therefore, self-administered questionnaires are widely used as a quick and inexpensive method to screen for hearing loss in clinical settings (Gates et al, 2003). Several questionnaires for assessing hearing disability have been developed and used by the English-speaking countries such as the hearing disability and handicap scale (HDHS) (Hetu et al, 1994), and the Gothenburg profile (GP) (Ringdahl et al, 1998). In 1982, Ventry and Weinstein introduced the 25-item hearing handicap inventory for the elderly (HHIE), to assess the selfperceived psychosocial handicap of hearing impairment in the elderly (Ventry & Weinstein, 1982). A shorter widely used 10-item version of the HHIE, the hearing handicap inventory for the elderly - screening (HHIE-S), was introduced in 1986 as a screening tool for handicapping hearing loss. This instrument consists of 10 questions designed to
Correspondence: Doha Rasheedy, MD, Geriatrics and Gerontology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt. E-mail: [email protected] (Received 6 April 2014; accepted 22 November 2014 ) ISSN 1499-2027 print/ISSN 1708-8186 online © 2015 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society DOI: 10.3109/14992027.2014.996827
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Abbreviations HHIE-S Hearing handicap inventory for the elderly - screening ICC Intraclass correlation coefficient PTA Pure-tone audiometer ROC Receiver operating characteristic
assess perceived emotional and social problems related to impaired hearing (e.g. frustration, embarrassment, or difficulty in certain situations). One of three responses (‘yes’, ‘sometimes’, or ‘no’) was recorded for each question and scored as 4, 2, or 0, respectively (Weinstein, 1986). The HHIE and its short form are of the most widely used instruments in English-speaking countries. They are also available in many languages, including Spanish (Lichtenstein & Hazuda, 1998), Brazilian Portuguese (Aiello et al, 2011), Italian (Monzani et al, 2007), Japanese (Sato et al, 2004), and Chinese (Jupiter & Palagonia, 2001). Although, Arabic is the fourth most commonly spoken language in the world and there are an estimated 221 million native Arabic speakers, who comprise 3.7% of the world’s population (Lewis, 2009), the HHIE and its short form, as well as many other screening questionnaires, lack sufficient validity for the Arabic speaking elderly, which limits their use in clinical and research settings. The aim of the present study was to cross-culturally adapt an Arabic version of the HHIE-S, and to validate the produced Arabic version in elderly Egyptians patients with hearing loss. The study methodology was reviewed and approved by the Research Review Board of the Geriatrics and Gerontology Department, Faculty of Medicine, Ain Shams University. Informed consent was taken from every subject participating in this study. The permission from the author was obtained, then the translation and cultural adaptation of the 10-item hearing handicap inventory for the elderly - screening questionnaire (HHIE-S) was produced by following the stages proposed by Beaton et al, 2000.
Stage 1: Translation of the 10-item HHIE-S Two initial forward translations of HHIE-S into Arabic were obtained by two bilingual translators whose mother tongue is Arabic. Then researchers approved an Arabic version using the original questionnaire as well as both translations. Later, back translation of the approved Arabic version into English was performed. The back-translator was a certified translator, native speaker of Arabic, and proficient in English. He was blinded to the original version of HHIE-S. The researchers reviewed all translations and the original questionnaire to reach consensus on any discrepancies and to produce a preliminary version for field testing.
Stage 2: Cultural adaptation of the Arabic (HHIE-S) and pretesting of the adapted form Three culturally appropriate equivalents were added to the Arabic HHIE-S to facilitate its use in elderly Egyptians. Two of the situational items in the original questionnaire referred to activities which were not commonly practiced by Egyptian elderly populations, such as outdoor dining and attending religious services.
So, the authors replaced them by two more culturally appropriate items from the original 25-item hearing handicap inventory (using the telephone and shopping). The third replaced item was the emotional item of feeling embarrassed when meeting new people. It was replaced by another emotional item (being upset by the hearing problem) because most of the Egyptian elderly prefer indoor activities and have a minimal chance of meeting new people. The final Arabic HHIE-S and suggested authors’ modifications were tested in a face to face interview of 20 elderly subjects with hearing impairment, randomly selected at the Audiology Unit in Ain Shams University Hospital. Their hearing loss was documented by pure-tone audiometry. To test for face validity and content validity, the respondents were probed for their understanding, acceptability, and the emotional impact of each item in order to detect confusing or misleading items. The respondents were asked to rephrase each item in their own way to identify whether an item was understood or not. Moreover, they were asked if they were accustomed to performing these activities.
Results of pretesting stage The mean age of the 20 subjects included in the pretest was 66.8 ⫾ 3.4 years; 60% of the participants were males and 40% were females. Ten of the participants were illiterate; four of them had less than five years of education, another five finished secondary school, and only one had college education. Minor modifications were made according to participants’ suggestions in items number 2 and 6. Three of the participants suggested replacing the word ‘frustrated’ by the word ‘upset’ in item 2. Four subjects suggested changing the phrase ‘attendance to religious ceremonies’ to ‘praying in congregation at the mosque or the church’ in item 6. The remaining items were fully understood and accepted by the patients; however, many subjects were not accustomed to performing the activities of meeting new people, attending religious ceremonies, or being in a restaurant. The patients’ responses are shown in Table 1.
Stage 3: The psychometric evaluation of the modified Arabic (HHIE-S) A new group of 100 consecutive subjects were recruited from the Geriatric Medicine Unit in Ain Shams University Hospital. Only those who consented were recruited to the study. All subjects were 60 years or older, and were (1) functionally independent (activity of daily living (ADL) Score ⫽ 6 (Katz et al, 1963), and instrumental activity of daily living (IADL) Score ⫽ 8 (Lawton & Brody, 1969)); (2) not acutely-ill (they didn’t need medical supervision or specialized nursing care for any co morbid conditions); (3) without cognitive impairment that interfered with interviewing the patient (mini mental state examination score ⱖ 26 indicates normal cognitive function (Folstein et al, 1975)); and (4) without previous use of hearing aids. Initially, the subjects were given general instructions of the HHIE-S by the researcher. The Arabic initial and three adapted items after the pre-testing stage were administered either by pen or in face to face interview for illiterate subjects. The responses were scored 0 for a no response, 2 for a sometimes response, and 4 for a yes response. The total score was the sum of all responses. Subjects reported when they weren’t accustomed to performing the activity due to any other cause rather than hearing impairment.
Validated Arabic Hearing Handicap Inventory
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Table 1. Patients’ responses obtained during pretesting phase. Patient’s response Item 1 2 2# 3 4 5 6 6# 7 8 9 10 11* 12* 13*
No Do hearing problems embarrass you when you meet new people? Does a hearing problem make you feel frustrated when you talk to your family members? Does a hearing problem make you feel upset when you talk to your family members? Do you find it difficult when someone speaks in a whisper? Do you feel that you have a disability because of a hearing problem? Does a hearing problem cause you difficulty when visiting friends and relatives, or neighbors? Does a hearing problem reduce your attendance to religious ceremonies more than you would like? Does a hearing problem reduce your praying in congregation at the mosque or the church? Does a hearing problem cause disputes between you and a family member? Does a hearing problem cause difficulty when you are listening to the radio or television? Do you feel that any difficulty in hearing limits or hinders your personal or social life? Does a hearing problem cause you difficulty when you are in a restaurant with relatives or friends? Does a hearing problem reduce your shopping more than you would like? Does a hearing problem reduce your use of the telephone more than you would like? Does any problem or difficulty with your hearing upset you at all?
Sometimes
Yes
5% (1) 35% (7)
40% (8) 45% (9)
10% (2) 20% (4)
20% (4) 50% (10) 20% (4)
50% (10) 35% (7) 60% (12)
30% (6) 15% (3) 20% (4)
15% (3)
40% (8)
_
70% (14) 15% (3) 50% (10) 5% (1)
25% (5) 55% (11) 35% (7) 5% (1)
5% (1) 25% (5) 15% (3) 5% (1)
25% (5) 15% (3) 25% (5)
35% (7) 55% (11) 15% (3)
25% (5) 30% (6) 60% (12)
Not accustomed 45% (9) _ _ _
45% (9)
5% (1) 85% (17) 15% (3)
*Added equivalent items. # modified original items.
After the first administration was completed, all subjects underwent otoscopic examination and audiometric testing by an audiologist blinded to the HHIE-S results. One hour later, the subjects had the second administration of the adapted Arabic 10 item HHIE-S by another interviewer. The responses from two administrations were collected for data analysis.
Audiometric screening test Audiometric screening was used to determine the presence of any organic hearing impairment and to categorize its severity based on PTA of the better ear. PTA between 0–25 dB was considered within normal limits, PTA ⬎ 25 dB indicated mild hearing loss, PTA ⬎ 40 dB indicated moderate hearing loss, and PTA ⬎ 60 dB indicated severe hearing loss. Pure-tone testing was conducted in a double walled sound treated room I.A.C model 1602 using a standard two-channel audiometer Ineracoustics, model AC 40; calibrated according to ANSI S.3.6, 1996 and connected to TDH 39 headphones, bone vibrator B71 and two loudspeakers for quasi free sound field testing. Hearing thresholds were measured in each ear for frequencies 1000, 2000, and 3000 Hertz (Hz). Bone conduction was evaluated when the air conduction threshold was ⬎ 15 dB in any of the frequencies used.
Statistical analysis Descriptive data were presented as mean, and standard deviation. The Arabic HHIE-S questionnaire was tested for reliability and construct validity. Reliability is defined as the degree in which the measured result reflects the true result. In the present study, reliability was measured by assessing the internal consistency and the test-retest consistency. The internal consistency of the questionnaire was measured by the Cronbach’s alpha. It was helpful in deciding whether different questions in a questionnaire were measuring the same underlying
concept and whether each item of the questionnaire was a consistent indicator of hearing handicap. A Cronbach’s alpha coefficient of 0.70 was the minimally acceptable level for internal consistency reliability. Cronbach’s alpha was also calculated when each item was removed from the questionnaire to establish how each item affected the reliability of the instrument. Regarding the test-retest consistency, comparison was made by calculating a Spearman’s correlation coefficient (rho) between the first and second administration of the questionnaire. We calculated intraclass correlation coefficients (ICCs) with corresponding 95% CIs for evaluating inter-rater reliability. ICCs above 0.70 were considered to be good repeatability Agreement between the adapted Arabic HHIE-S and audiometry was evaluated using Spearman’s correlations (rho) to establish construct validity of the questionnaire. The ROC curve was used to find the optimal cut-off point for detecting hearing impairment. Sensitivity, specificity, positive predictive value, and negative predictive values were calculated for possible cut off points. Statistical analysis was done on a personal computer using IBM© SPSS© Statistics version 16 (IBM Corp., Armonk, USA). A p-value of ⬍ 0.05 indicated statistical significance.
Results of psychometric evaluation of the adapted Arabic (HHIE-S) Among 100 patients enrolled in the study, 44% (n ⫽ 44) of the subjects tested positive using audiometry for hearing impairment. Seven percent (n ⫽ 7) had severe hearing impairment, 16% (n ⫽ 16) had moderate hearing impairment, and 21% (n ⫽ 21) had mild hearing impairment according to the pre-defined criteria. The remaining 56% (n ⫽ 56) had normal hearing. The mean HHIE-S scores were 29.7 ⫾ 6.36, 20.0 ⫾ 9.38, 9.8 ⫾ 6.13, and 3.5 ⫾ 2.86, respectively. The demographic data of the participants is shown in Table 2.
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Table 2. Demographic data of patients with and without hearing impairment.
Variable Age (years) Gender, n (%) Female Male
Without hearing loss impairment (n ⫽ 56)
With hearing loss impairment (n ⫽ 44)
68.32 ⫾ 6.80
66.47 ⫾ 6.02
22 (39.30%) 34 (60.70%)
20 (45.50%) 24 (54.50%)
P* 0.13 0.53
Table 3. Construct validity and reliability of the adapted Arabic HHIE-S. Construct validity
Reliability
Spearman correlations between the adapted Arabic (HHIE-S) item and audiometry results
The internal consistency of the adapted Arabic (HHIE-S)
Item Education, n (%) Illiterate (can’t read or write) Less than 5 years of education Secondary school College Living arrangement, n (%) Alone With spouse With offspring Social class, n (%) Low social class Middle social class High social class Arabic (HHIE-S) score (mean⫾ SD)
0.46 20 (35.70%)
16 (36.40%)
5 (8.90%)
2 (4.50%)
16 (28.60%) 15 (26.80%)
18 (40.90%) 8 (18.20%)
3 (5.40%) 36 (64.30%) 17 (30.40%)
2 (4.50%) 35 (74.50%) 7 (15.90%)
24 (42.90%) 32 (57.10%) 0 3.50 ⫾ 2.80
22 (50%) 21 (47.70%) 1 (2.30%) 16.60 ⫾ 10.40
0.22
0.37
0.00*
Values are mean ⫾ SD or n (%) independent t test, chi-square test where appropriate. *statistically significant.
According to subjects’ responses, it was reported that 18% of subjects were not accustomed to meeting new people, 50% did not attend religious ceremonies, 92% were not accustomed to outdoor dining, while only 3% did not visit acquaintances, and 8% were not used to shopping. To determine the construct validity, the total Arabic HHIE-S score and individual item scores were compared to PTA outcomes using Spearman’s correlation coefficients. It ranged between 0.35–0.67 for adapted Arabic HHIE-S items, and it was 0.68 for the total score. The significant correlations between each HHIE-S item, total score and PTA outcome suggested that the adapted Arabic HHIE-S had adequate construct validity (Table 3). Reliability in the form of internal consistency and test-retest reliability was assessed. Internal consistency refers to the extent to which items within the questionnaire are related to each other. The Cronbach’s coefficient alpha and item-total correlation coefficients were generated to examine the internal consistency of the HHIE-S (Table 3). In the current study, the Cronbach’s alpha is 0.902, which indicates a high level of internal consistency for the adapted Arabic HHIE-S. Observation of the item-total correlation revealed two low correlations: item 2 (r ⫽ 0.46) and item 3 (r ⫽ 0.38); yet, the two items were kept in the questionnaire because calculating α without item 2 (α ⫽ 0.869), and item 3 (α ⫽ 0.891) decreased the overall Cronbach’s alpha of the 10 items. Test-retest reliability assessed the degree to which the results were consistent over time and when rated by different interviewers. Mean scores and Spearman’s correlations of the test-retest are presented in
Q2 Q3 Q4 Q5 Q7 Q8 Q9 Q 11 Q 12 Q 13 Total score
r
P value
Item
0.64 0.51 0.57 0.35 0.51 0.42 0.53 0.61 0.41 0.67 0.68
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Q2 Q3 Q4 Q5 Q7 Q8 Q9 Q 11 Q 12 Q 13
Corrected item: Total correlation
Cronbach’s alpha (if item deleted)
0.46 0.38 0.86 0.59 0.71 0.61 0.81 0.58 0.80 0.87 Cronbach’s alpha:
0.869 0.891 0.878 0.896 0.893 0.896 0.883 0.897 0.882 0.879 0. 902
Construct validity confirmed by assessment of correlation between the adapted Arabic HHIE-S item and PTA using Spearman’s correlations, the internal consistency of the adapted Arabic HHIE-S using Cronbach’s Alpha.
Table 4. Test-retest correlations were sufficiently high for all items, suggesting good questionnaire stability over time (ranged from 0.82 for item 3 to 0.97 for total score). We calculated intraclass correlation coefficients (ICCs) with corresponding 95% CIs (ranged from 0.633 for item 5 to 0.986 for total score) which suggested a good agreement between different examiners (Table 4). The ROC curve was used to determine the degree to which the adapted Arabic HHIE-S could detect the degree of hearing loss (HL). The area under curve (AUC) was 0.945, 0.953, and 0.954 for predicting mild, moderate, and severe HL, respectively (Figure 1).
Table 4. Test re-test reliability descriptive statistics and repeatability measures of the Arabic HHIE-S. Mean score of the modified Arabic HHIE-S
Item Item 2: score Item 3: score Item 4: score Item 5: score Item 7: score Item 8: score Item 9: score Item 11: score Item 12: score Item 13: score Total score
First Second ICC administration administration Spearman’s r (95% CI) 1.28 ⫾ 1.49 2.70 ⫾ 1.56 0.68 ⫾ 1.39 0.44 ⫾ 1.04 0.38 ⫾ 0.88 0.76 ⫾ 1.35 0.58 ⫾ 1.21 0.56 ⫾ 1.10 1.20 ⫾ 1.40 0.72 ⫾ 1.28 9.30 ⫾ 9.43
1.3 ⫾ 1.48 2.50 ⫾ 1.52 0.66 ⫾ 1.36 0.4 ⫾ 1.02 0.44 ⫾ 0.96 0.78 ⫾ 1.33 0.56 ⫾ 1.24 0.56 ⫾ 1.10 1.30 ⫾ 1.48 0.76 ⫾ 1.29 9.30 ⫾ 9.74
0.98 0.82 0.95 0.86 0.92 0.95 0.94 1.00 0.94 0.96 0.97
0.99 0.85 0.96 0.63 0.86 0.95 0.96 0.95 0.93 0.97 0.98
ICCs: Intraclass correlation coefficients. CI: Confidence interval. ICCs above 0.70 were considered to be good repeatability.
Validated Arabic Hearing Handicap Inventory
Figure 1. Receiver operating characteristic (ROC) curve for using the adapted Arabic (HHIE-S) to predict hearing loss in elderly. The ROC curve shows that the adapted Arabic HHEI-S had an area under the curve of 0.945, 0.953, and 0.954 for predicting mild, moderate and severe HL, respectively. Based on the sensitivity and specificity of the different cut-off points of the adapted Arabic HHIE-S for detecting the severity of hearing loss, the score ⬎ 6 was useful in detecting mild hearing loss (The sensitivity and specificity were 84% and 67.8%, respectively). The sensitivity and specificity for detecting moderate HL were 83% and 87% respectively when the cut-off score was ⬎ 12. The score ⬎ 26 detected severe HL with 85.7% sensitivity and 94.6% specificity (Table 5).
Discussion Hearing impairment in the elderly can pass undetected because the elderly and their treating physician consider it a physiological aging Table 5. Summary of statistics of different scoring cut-off values of the modified Arabic HHIE-S predicting the degree of hearing loss as defined by pure-tone audiometry. Positive if greater than or equal to
Sensitivity
Specificity
Mild hearing loss (26–40 dB HL) 6 points 84.00% 67.80% 8 points 75.00% 87.50% 10 points 72.70% 98.20% 12 points 65.00% 100.00% Moderate hearing loss (41–59 dB HL) 12 points 83% 87% 14 points 78.20% 90.70% 16 points 73.90% 94.80% 20 points 65.20% 98.70% Severe hearing loss (⬎ 60 dB HL) 26 points 85.70% 94.60% 28 points 85.70% 94.60% 32 points 85.70% 96.70%
PPV
NPV
67.20% 82.50% 96.90% 100.00%
84.40% 81.60% 82.00% 78.80%
66.60% 72.00% 80.90% 93.70%
94.30% 93.20% 92.40% 90.40%
54.50% 60.00% 66.60%
98.80% 98.80% 98.90%
NPV: negative predictive value (percentage with a negative screening test who did not have hearing loss); PPV: positive predictive value (percentage with a positive screening test that had hearing loss).
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process. So, self-report scales may help those elderly with early diagnosis and severity detection of their hearing problem (Hidalgo et al, 2008). In this study, the reliability and validity of the adapted Arabic HHIE-S were examined, and its clinical utility for discriminating hearing impairment was proved using the ROC curve. In this study, to cross-culturally adapt the questionnaire, the items that were not practiced in the target culture were replaced by more suitable ones. Results showed that 18% of subjects were not accustomed to meeting new people, 50% did not attend religious ceremonies, and 92% were not accustomed to outdoor dining. Thus, telephone use and shopping were more suitable situational items, and feeling upset with hearing problem was a more suitable emotional item than feeling embarrassed when meeting new people. Although the HHIE-S was developed as a self-administered questionnaire, the low literacy rate among the subjects made them unable to complete the questionnaire by themselves, so we used a face to face interview to complete the questionnaire when required. The test-retest correlation for the total adapted Arabic (HHIE-S) score and each item score were significant (first administration: mean ⫽ 9.30, SD ⫽ 9.43; second administration: mean ⫽ 9.30; SD ⫽ 9.74; rho ⫽ 0.97, p ⬍ 0.001). This result suggested that the questionnaire had acceptable stability over time; however, the one hour interval between the two administrations may not be sufficient for test-retest reliability. The present study selected to retest in the same day in order to make it possible to keep track of the subjects. It was confirmed that the subjects did not memorize the first administration because some subjects did not repeat the same response on some items in the second administration. Our findings demonstrated that the HHIE-S adapted to the Arabic language maintained its original reliability and validity. The original English HHEI-S had internal consistency reliability (Cronbach’s alpha) of 0.87. Test-retest reliability was reported at 0.84 (P ⬍ 0.0001) (Weinstein, 1986). In the current study, the adapted Arabic HHEI-S showed good internal consistency (α ⫽ 0.902). Spearman’s correlation coefficients between the total score of the adapted Arabic HHIE-S and PTA confirmed a good construct validity of the questionnaire (rho ⫽ 0.688, p ⫽ 0.000). Repeatability of the questionnaire was high (ICC ⫽ 0.986). This data agreed with a study performed in Japan to validate HHEI-S. The reported Cronbach’s alpha coefficient was 0.91, Spearman’s coefficient of the total score was 0.90, and intra-class correlation coefficient was 0.85 (Tomioka et al, 2013). The lower Spearman’s correlation coefficients in our study may be attributed to a limitation of not conducting audiometric evaluation at frequencies above 3000 Hz, causing poorer correlation between HHEI-S score and PTA results; however, two previous validation studies were conducted similarly by comparing to audiometric thresholds at 1000/2000 Hz (Gates et al, 2003) or 1000/3000 Hz (Wu et al, 2004). However, the intra-class correlation coefficient was higher in the current study due to shorter time interval between the two administrations of the questionnaire. Regarding the discriminant validity, the adapted Arabic HHIE-S showed good ability to discriminate between patients with and without hearing impairment. The mean score was 16.6 ⫾ 10.4 vs. 3.5 ⫾ 2.8 respectively (p ⫽ 0.000). Moreover, the adapted Arabic HHIE-S was also capable of discriminating between different degrees of hearing loss. The mean HHIE-S scoring in the current study was 3.5 ⫾ 2.86, 9.8 ⫾ 6.13,
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20.0 ⫾ 9.38, and 29.7 ⫾ 6.36 for patients without hearing loss, with mild impairment, moderate impairment, and those with severe hearing loss, respectively. Therefore, it is strongly suggested that HHIE-S should be incorporated in the comprehensive geriatric assessment to screen for handicapping hearing impairment. According to Jupiter and DiStasio, the mean HHIE-S scoring was 3.7 ⫾ 4.9, 6.7 ⫾ 9.7, 14.0 ⫾ 10.5, and 20.5 ⫾ 8.8 for patients without hearing loss, with mild impairment, moderate impairment, and those with severe hearing loss, respectively (Jupiter & DiStasio, 1998). The prevalence of hearing loss detected by pure-tone audiometry in this study was 44% which is comparable to earlier studies. The prevalence of hearing loss was 39.4% among the elderly in the Blue Mountain Hearing Study (Sindhusake et al, 2001), and 36.9% in a study done among the elderly in Malaysia among subjects aged 55–99 years (Rosdina et al, 2010). Higher prevalence of hearing loss was observed in other studies (Deepthi & Kasthuri, 2012), where the prevalence of hearing loss was 72% among the Indian elderly population. The differences could be due to differences in the population studied, sample size and the pure-tone audiometry criteria used for diagnosing hearing loss.
Conclusions The results suggest that the Arabic HHIE-S is a reliable and valid screening tool for hearing loss suitable for use in clinical settings and research studies among the Egyptian elderly population.
Acknowledgements The authors would like to thank Ain Shams University Hospital for supporting this research. Declaration of interests: The authors declare no conflicts of interest with respect to the authorship or publication of this article. The authors received no financial support for the research or authorship of this article.
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Supplementary material available online Supplementary Appendix available online at http://informahealthcare.com/doi/abs/ 10.3109/14992027.2014.996827.
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