Validity of the Italian adaptation of the Hearing Handicap Inventory for the Elderly (HHIE-It)
Objective. The aim of this study was to assess the validity and reliability of the Italian translation of the Hearing Handicap Inventory for the Elderly (HHIE).
Methods. A sample of 275 adults, aged > 65 years, filled out the Italian version of the HHIE (HHIE-It) together with the MOS 36-Item Short Form Health Survey (SF-36). Seventy-one participants answered the questionnaire a second time after six weeks. The internal consistency, test-retest reliability, construct and criterion validity were evaluated.
Results. Cronbach’s alpha was 0.94 and suggested a high internal consistency. There was also a significant intraclass correlation coefficient (ICC) between test and retest scores. In addition, Pearson’s correlation coefficient between the two scores was high and significant. High and significant correlation coefficients were also found between the HHIE-It score and the pure tone average threshold of the better ear and between the HHIE-It and the subscales Role-emotional, Social Functioning and Vitality of the SF-36. These latter results indicate good construct and criterion validity, respectively.
Conclusions. The HHIE-It maintained the reliability and validity of the English version suggesting its utility for both clinical and research purposes.
Population aging is defined as the progressive lengthening of life expectancy associated with an increasing number of elderly persons in any population. The economic effects of increased population ageing are considerable and new challenges to health care systems should be considered. In fact, there were 727 million people aged 65 years or above (9.3% of the total world population) in 2020 and this number is expected to consistently increase to about 1.5 billion or approximately 16% of the total world population by the year 2050 according to the United Nations 1. Age-related hearing loss (ARHL), or presbycusis, is one of the most common conditions affecting older adults and is the third most prevalent chronic condition after hypertension and arthritis. Since population ageing is the most significant predictor of hearing loss, it is not surprising that nearly one of four individuals aged 65 to 74 and one of two of those 75 and older are affected 2,3. Taken these epidemiological data together, audiological services are expected to be increasingly overwhelmed with older patients with hearing loss in the future. One of the most intriguing questions arising from this scenario is the methodology that should be considered the most appropriate to fully assess hearing loss disability and handicap in older people. Hearing loss is a barrier to communication and easily gives origin to a cascade of relevant consequences such as withdrawal from social interaction, depression and increased risk for cognitive decline 4. If audiometric measures alone directly reflect the magnitude of sensory deprivation, the difficulties encountered by the listener in daily real-life, their consequences on social attitudes and psychological well-being need more exhaustive tools. Ventry and Weinstein, after investigating and carefully analysing other research on this topic, developed a new, self-assessment tool designed to quantify the effects of hearing impairment on the emotional and social adjustment to hearing loss in elderly people: the Hearing Handicap Inventory for the Elderly (HHIE) 5. The original English version of this questionnaire was found to be valid and reliable 5,6. Its translations have been carried out across different countries and cultures 7-11. To our knowledge, since no study has adapted it to the Italian language, the aim of the present study is to validate an Italian version of the questionnaire (HHIE-It) and test its psychometric properties in a sample of community-dwelling older adults.
Materials and methods
A cohort of 275 subjects was recruited for this study from May 2018 to June 2019. This sample size was adopted in accordance with a predetermined respondent-to-item ratio of 10:1 12. The subjects were consecutive outpatients attending the audiological centre at the Audiology Unit, IRCCS Fondazione Policlinico, Mangiagalli e Regina Elena, University of Milan (Italy). The following inclusion criteria were established: both genders, age > 65 years, speaking Italian as their first language and willing to participate in the study. No segregation of cases was made on the basis of type of hearing loss (conductive, sensorineural and mixed). Patients with unilateral or bilateral loss of hearing were both invited to participate. The following exclusion criteria were established. Firstly, the presence of major neurological or psychiatric disorders or any other morbidity that could prevent them from understanding and answering the self-administered questionnaires by paper and pencil. Patients with cultural barriers that could prevent them from understanding the questionnaire items were excluded. Furthermore, subjects with fluctuating hearing loss and balance disorders, or wearing hearing aids/cochlear implants were not included.
After otoscopic examination and immittance audiometry, each patient was seated within a double-wall, sound booth that complies with ISO 8253 and in the window view of the examiner but not of the audiometric controls board. Audiological screening of each subject was carried out using a Type 1 two-channel diagnostic audiometer (MADSEN Astera 1066 type, GN Otometrics A/S) and managing data using integrated OTO suite software. The examiners followed the Hughson-Westlake method of obtaining air conduction thresholds for each ear. The four frequency (0.5 KHz, 1 KHz, 2 Khz, 4 KHz) pure tone average threshold (4fPTA) was computed for both ears and then the better ear 4fPTA of each participant was used for statistical analysis. According to the WHO’s Grades of hearing impairment 13, a 4fPTA ≤ 25 dB HL means no impairment, 26 dB HL ≤ 4fPTA ≤ 40 dB HL mild impairment, 41 dB HL ≤ 4fPTA ≤ 55 dB HL suggests moderately-severe impairment, 56 dB ≤ 4fPTA ≤ 70 dB indicates severe impairment and a 71 dB HL ≤ 4fPTA < 90 dB HL represents profound impairment.
As is the original English version of the HHIE, the Italian translation is 25-item questionnaire (HHIE-It) that is comprised of two subscales: a 13-item subscale explores the emotional consequences of hearing impairment (E); a 12-item subscale explores both social and situational effects (S) (Appendix I). A NO answer to an item is awarded 0 points, SOMETIMES 2 points and YES 4 points. The possible scores of E and S are between 0 and 52 and 0 and 48, respectively. Therefore, the total score ranges from 0 to 100 points, with higher scores indicating a greater level of perceived handicap. The original version was translated using a forward and backward technique that complies with the standards established by the IQOLA (International Quality of Life Assessment) project 14, for academic use and under license by the original authors. Before starting the present study, the HHIE-It was preliminarily administered in a pilot sample of 28 hearing-impaired patients with varying educational and social status, in a face-to-face interview format. Since few doubts about wording and comprehensiveness occurred, only a minor revision of the items was carried out. In order to provide evidence of criterion-related validity for HHIE-It, all patients were also asked to complete the Italian version 15 of an existing and already validated instrument that measures the psycho-sociological domains of health-related quality of life, the MOS 36-Item Short Form Health Survey (SF-36) 16. This questionnaire investigates health status in the past four weeks on eight subscales: general health, physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional and mental health. Each dimension is separately scored using item weighting and additive scaling. Summed data were then transformed into a 0 to 100-point scale with higher score indicating better condition. Similar to a previous validation study of the Hearing Handicap Inventory for Adults 17, we employed the social-functioning (SF) and the role-emotional (RE) subscales as analogues of the correspondent S and E subscales of the HHIE-It. The SF subscale evaluates the impact of physical and emotional problems on social activities (with family, friends, neighbours and groups), while the RE rates the interference of emotional problems (such as feeling depressed or anxious) with regular daily activities. In the framework of this work, we also used the subscale ‘vitality’ (V) of the SF-36. This subscale is generally accepted to be a valid measure of energy/fatigue 18. As a fact, increasing evidence from audiological medicine suggests that fatigue, as opposed to vigour and energy, is a relevant factor in the perceived hearing handicap 19.
Epidemiological features of the participants, such as gender, age and 4fPTA, were reported with descriptive statistics and an independent t-test was used to compare the continuous variables between males and females. In addition, the total score of the HHIE-It as well as the scores of its subscales were reported with descriptive statistics (Tab. I). Internal and test-retest consistencies of the HHIE-It were adopted to test reliability. The former was assessed with Cronbach’s α 20. According to this model, the more items in a test are correlated with each other (inter-item correlations), the greater the value of α. Alpha coefficients ≥ 0.70 are generally considered indicative of acceptable reliability of the scale 12, even if the use of cut-off values is debated. In addition, the statistical procedure “Cronbach’s α if item is deleted” was adopted. This procedure is intended to verify if the removal of one or more items from the scale improves the overall α coefficient. HHIE-It was administered a second time to 71 selected subjects who responded with no change in their hearing ability after a six weeks interval in a phone-interview format to assess test-retest consistency. This is essential to measure the stability of the scores over time and comparison was made by calculating both the Pearson’s correlation between the two surveys and the ICC. In this study, ICC estimates and their 95% confident intervals were calculated based on single measures, absolute-agreement and a 2-way mixed-effects model. The predetermined, minimally acceptable ICC value was set at 0.8. Construct validity of the HHIE-It refers to the ability of a survey to measure an intended hypothetical construct. It was assumed that higher scores of HHIE-It and its subscales should directly correlate to the degree of hearing loss. We used Pearson’s correlation coefficient to disclose the presumed correlation between 4fPTA (dB HL) and the total score of HHIE-It and its subscales. As already mentioned, the Italian version of the MOS 36-Item Short Form Health Survey (SF-36) 15 was employed to assess criterion-related validity of the questionnaire and its subscales. The HHIE-It total score was correlated to the vitality (V) subscale score of the SF-36, whereas the S and E subscales scores were correlated to the social functioning (SF) and the role-emotional (RE) subscales of the same questionnaire, respectively. Pearson’s correlation coefficient was used. Finally, ceiling and floor effects were computed and considered present if more that 15% of the patients reported the minimum (0) or the maximum (100) score of the scale 21. Significance was considered if the p-value was < 0.05. Data analysis was performed using the Statistical Package for Social Sciences (SPSS version 23.00) software (SPSS, Inc., Chicago, Il, USA).
Of the 275 outpatients recruited and examined, 160 were males (58.2%) and 115 females (41.8%). The mean age was 74.5 years (SD = 6.6, range: 65-91). Table I shows the demographic characteristics of the sample. According to the WHO’s Grades of hearing impairment 13 based on 4fPTA, 15 patients (5.5%) had no impairment, 44 (16.0%) had a slight impairment, 87 (31.6%) had mild impairment, 88 (32.0%) had moderate impairment, 33 (12.0%) had moderately-severe impairment, 6 (2.2%) had severe impairment and 2 (0.7%) profound impairment (Fig. 1). The mean value of 4fPTA was 39.3 dB HL (range: 10-111.3, SD = 16.0). Males were significantly older than females (t = -3.06, df = 273, p = 0.002), but the degree of hearing loss in the better ear did not differ between gender (t = 1.9, df = 255, p = 0.056). Table II shows the total score of the HHIE-It and the scores of the two subscales, E and S. No significant difference was found between males and females with regards to the HHIE-It total score (t = -0.58, df = 268.4, p = 0.557), the S score (t = -0.231, df = 268.9, p = 0.817) and E score (t = 0.837, df = 266.2, p = 0.403). Cronbach’s α coefficient was 0.94 for the total score of the questionnaire, and 0.84 and 0.93 for the S and E subscales, respectively. The procedure ‘Cronbach’s α if item is deleted’ pointed out that removal of item 21 improved overall α coefficient of the scale to 0.957. After its removal, no other item was shown to increase α again. Pearson’s correlation coefficient between the total scores of the HHIE-It obtained in the two distinct administrations was 0.392 (2-tails significance = 0.002). ICC resulted 0.888 for HHIE-It total score, 0.828 and 0.884 for the E and S subscales, respectively (Tab. III). Pearson’s correlation coefficient between 4fPTA and HHIE-It total score was 0.408 (2-tails significance < 0.001). Highly significant correlations were also found between 4fPTA and the E and S subscales of the HHIE-It (r = 0.358, 2-tails significance < 0.001 and 0.329, 2-tail significance < 0.001). Negative correlations were found between the HHIE-It and its subscales (S, E) scores and the three SF-36 subscales scores (SF, RE and V) (p < 0.001) (Tab. IV). Finally, no ceiling effect was found since no patients scored 100 at HHIE-It and only 8 patients (3%) a minimum score (0).
Cronbach’s α coefficient of the Italian version was 0.941 which is very close to that of the original study of Ventry and Weinstein (0.95) 5 and the Swedish adaptation (0.92) 7. Moreover, Cronbach’s α of the E and S subscales (0.84 and 0.93, respectively) closely resemble those of the original version (0.88 and 0.93). Only the removal of item 21 from the scale slightly improved the overall α coefficient of the scale. However, item 21 “Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?” investigates one of the most common complaints among older hearing-impaired patients, namely speech understanding in competing background noise 22. We decided not to remove it from the scale because it is “necessary and desirable” for audiologists 5 to pinpoint any specific situation that could be detrimental to social adjustment even if not so frequently encountered by the elderly in everyday life. In fact, this study suggested the internal consistency of the HHIA-It to be more than acceptable and all the items of the scale are consistent indicators of hearing handicap. According to George and Mallery 12, α values equal or greater than 0.9 are to be considered excellent. On the other hand, a very high α value could indicate redundancy between items in the scale, but exploring the possibility of a shorter version was beyond the purpose of this validation study. Many factors can affect the score of a questionnaire at different points in time: for instance, patients’ responses might be influenced by pathological changes, different moods, or external conditions. Furthermore, the subject’s memory of the scale items might contribute to an exceedingly strong correlation between the two surveys. As a rule of thumb, an interval time of at least six weeks between the two administrations adopted in this study is suggested to counteract this latest factor 23. Thus, both a significant Pearson’s correlation coefficient and ICC between the scores of the questionnaire and its subscales suggest that the HHIE-It resists all the other risks. Compared to other adaptations of audiological disease-specific questionnaires into Italian language 23, construct validity of HHIE-It was shown to be more straightforward because a robust and direct correlation between an objective measure of hearing impairment (4fPTA) and perceived hearing handicap was documented. In other words, HHIE-It scores improve as the degree of hearing loss increases in accordance with the predetermined hypothetical concept adopted in this study. Criterion validity was confirmed by significant correlations between HHIE-It overall score and the scores of its subscales E and S with the corresponding RE and SF of the SF-36. These results confirm that hearing handicap is related to both psychological distress and poor social adjustment. Difficulties in taking part in conversation with relatives and friends and subsequent frustration facilitate loneliness and depression. In addition, this study disclosed a negative correlation between the severity of subjective hearing handicap and vitality, as assessed by the V subscale of the SF-36. Indeed, lack of energy, exhaustion and chronic feelings of fatigue could be associated with hearing loss through the increased listening effort 24. Furthermore, dissipated vigour arising from daily life engagement of cognitive resources for speech perception may be one of the most relevant contributors to hearing loss related disability 25. Another important factor of this validation study is the exclusion of ceiling and floor effects of the HHIE-It questionnaire, which indicate the percentages of respondents scoring the highest (ceiling) or lowest (floor) extremes of the scale. If a large proportion of patients report the highest or lowest possible score for a questionnaire, then the tool is not adequate to distinguish between respondents at the extreme ends of the scale 21. Since the floor/ceiling effect was really scarce in this sample of hearing-impaired older adults, this risk was considered negligible. Some limitations of this study are pertinent. A limitation of this study was the absence of patients wearing hearing aids so that HHIE-It cannot provide any information about the outcome of intervention. To this purpose, a new trial on the benefit of aural rehabilitation in the elderly is ongoing and the HHIE-It is the main tool adopted to detect reduction of perceived handicap after hearing aids fitting. Furthermore, this study did not include any institutionalised older adults with hearing impairment. In view of this, there is a concern about the active ageing process, in which the continuing participation of aged people on daily activities is enhanced with respect to their hospitalised peers.
This study demonstrates that the Italian adaptation of the HHIE is a valid and reliable instrument to investigate the amount of perceived handicap related to hearing impairment in the community-dwelling older adults. The HHIE-It demonstrated favourable psychometric properties overlapping those of the original version and its adoption is justified for both clinical and research purposes in Italy.
Conflict of interest statement
The authors have no personal, financial, and institutional interest in any of the materials and devices described in this article.
FD: conception and design of the study, drafting the manuscript; RN: methodology, supervision, drafting of manuscript; BA: investigation, acquisition of data; EA: statistical analysis, editing the manuscript; CG: acquisition of data, conception of the study; DM: conception and design of the study, statistical analysis, editing the manuscript, final approval. All Authors contributed to the article and approved the submitted version.
The experimental protocol followed the recommendations of the last revision of WMA Declaration of Helsinki for Human experimentation published in October 2013 and written informed consent was obtained from each participant before assessment. The study was approved by the local Ethic Committee (Protocol N. 478-2016bis).
Figures and tables
|Total (n = 275)||Male (n = 115)||Female (n = 160)|
|4fPTA (dB HL)||39.3||16.1||10-101||40.8||16.4||10-101||37.2||15.3||10-85|
|Total (n = 275)||Male (n = 115)||Female (n = 160)|
|HHIE-IT (total score)||22.4||19.7||(0-92)||21.8||21.3||(0-92)||23.2||17.4||(0-80)|
|HHIE-IT (E subscale)||11.7||11.3||(0-52)||11.3||12.1||(0-52)||12.4||10.2||(0-38)|
|HHIE-IT (S subscale)||10.6||9.1||(0-46)||10.5||9.8||(0-44)||10.8||7.9||(0-42)|
|ICC||95% Confidence interval||F Test with true value 0|
|Lower Bound||Upper Bound||Value||df1||df2||P value|
|HHIE-IT (total score)||0.888||0.817||0.932||37.3||60||60||< 0.001|
|HHIE-IT (E subscale)||0.828||0.727||0.894||10.4||60||60||< 0.001|
|HHIE-IT (S subscale)||0.844||0.751||0.904||11.6||60||60||< 0.001|
|HHIE-IT (total score)||Pearson’s coefficient||-0.333**||-0.254**||-0.330**|
|Sig. (2-tails)||p < 0.001||p < 0.001||p < 0.001|
|HHIE-IT (S subscale)||Pearson’s coefficient||-0.327**||-0.241**||-0.313**|
|Sig. (2-tails)||p < 0.001||p < 0.001||p < 0.001|
|HHIE-IT (E subscale)||Pearson’s coefficient||-0.320**||-0.250**||-0.325**|
|Sig. (2-tails)||p < 0.001||p < 0.001||p < 0.001|
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