10.14639/0392-100X-N2297
Objective. Validate the Italian version of the Hearing Handicap Inventory for Elderly - Screening version (HHIE-S-It). Methods. After translation, psychometric properties and attributes were analysed by administering the HHIE-S-It to 167 elderly outpatients together with the Psychological General Well-Being Index (PGWBI). Results. The Cronbach’s α coefficient was 0.908 for the total score, and 0.832 and 0.816 for its two subscales. Significant test-retest reliability was observed (p &lt; 0.001). Moderate to high correlations were found between HHIE-S-It and pure tone average in the better ear (p &lt; 0.001). The ANOVA test confirmed the significant difference in HHIE-S-It scores across groups according to the degree of hearing loss (p &lt; 0.001). Only very low and low significant correlations were observed between HHIE-S-It and PGWBI. The criterion HHIE-S-It &gt; 11 was observed as the best cut-off with highest sensitivity (86.4%), specificity (72.4%), positive predictive value (52.8%), negative predictive value (93.7%) and likelihood ratios (3.12 and 0.19). Conclusions. Since the HHIE-S-It presented acceptable psychometric properties, its adoption is justified for both clinical and research purposes. Acceptable diagnostic attributes allow its use as a screening tool for age-related hearing loss.
text/xml
1827-675X
2297
en
Riccardo Nocini
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
hearing aids
Italian validation of the Hearing Handicap Inventory for Elderly – Screening version (HHIE-S-It)
Text.Serial.Journal
https://www.actaitalica.it/
43
Audiology
2023-07-24
2022-09-09
2023-07-25
2023-07-25
262-272
1
Riccardo Nocini
2023/07/24
10.14639/0392-100X-N2297
262
Section of Ear, Nose and Throat (ENT), Department of Surgical Sciences, Dentistry, Gynaecology and Paediatrics, University of Verona, Borgo Roma Hospital, Verona, Italy
1827-675X
hearing aids
en
272
Italian validation of the Hearing Handicap Inventory for Elderly – Screening version (HHIE-S-It)
https://www.actaitalica.it/article/download/2297/1014
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:262-272; doi: 10.14639/0392-100X-N2297




Audiology


Italian validation of the Hearing Handicap Inventory
for Elderly – Screening version (HHIE-S-It)
Validazione italiana dell’Hearing Handicap Inventory for Elderly – Screening version
(HHIE-S-It)
Enrico Apa1, Luca Sacchetto2, Silvia Palma3, Chiara Cocchi4, Chiara Gherpelli1, Elisabetta Genovese1,
Daniele Monzani2, Riccardo Nocini2
1
  Department of Medical and Surgical Sciences for Children and Adults, Otorhinolaryngology Unit, University of Modena
and Reggio Emilia, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy; 2 Section of Ear, Nose and Throat (ENT),
Department of Surgical Sciences, Dentistry, Gynaecology and Paediatrics, University of Verona, Borgo Roma Hospital, Verona, Italy;
3
  Audiology, Primary Care Department; AUSL of Modena, Modena, Italy; 4 Department of Sensorial Organs, Otorhinolaryngology
Section, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy


SUMMARY
Objective. Validate the Italian version of the Hearing Handicap Inventory for Elder-
ly - Screening version (HHIE-S-It).
Methods. After translation, psychometric properties and attributes were analysed by ad-
ministering the HHIE-S-It to 167 elderly outpatients together with the Psychological Gen-
eral Well-Being Index (PGWBI).
Results. The Cronbach’s α coefficient was 0.908 for the total score, and 0.832 and 0.816
for its two subscales. Significant test-retest reliability was observed (p < 0.001). Moderate
to high correlations were found between HHIE-S-It and pure tone average in the better ear
(p < 0.001). The ANOVA test confirmed the significant difference in HHIE-S-It scores across
groups according to the degree of hearing loss (p < 0.001). Only very low and low significant
correlations were observed between HHIE-S-It and PGWBI. The criterion HHIE-S-It > 11 was              Received: September 9, 2022
observed as the best cut-off with highest sensitivity (86.4%), specificity (72.4%), positive pre-     Accepted: January 22, 2023
dictive value (52.8%), negative predictive value (93.7%) and likelihood ratios (3.12 and 0.19).
Conclusions. Since the HHIE-S-It presented acceptable psychometric properties, its adop-              Correspondence
tion is justified for both clinical and research purposes. Acceptable diagnostic attributes           Enrico Apa
                                                                                                      Department of Medical and Surgical Sciences for
allow its use as a screening tool for age-related hearing loss.
                                                                                                      Children and Adults, Otorhinolaryngology Unit,
KEY WORDS: presbycusis, hearing impairment, social adjustment, public health, hearing aids            University of Modena and Reggio Emilia, Azienda
                                                                                                      Ospedaliero-Universitaria of Modena, largo del
                                                                                                      Pozzo 71, 41125, Modena, Italy
RIASSUNTO                                                                                             Tel. +39 059 4222806; +39 059 4225660
Obiettivo. Tradurre e validare in italiano l’Hearing Handicap Inventory for Elderly – Scre-           E-mail: apa.enrico@gmail.com
ening version (HHIE-S-It).
Metodi. Sono state analizzate le proprietà psicometriche e diagnostiche somministrando                  How to cite this article: Apa E, Sacchetto
l’HHIE-S-It a 167 pazienti ambulatoriali anziani insieme allo Psychological General Well-               L, Palma S, et al. Italian validation of the
Being Index (PGWBI).                                                                                    Hearing Handicap Inventory for Elderly –
Risultati. Il coefficiente α di Cronbach è risultato pari a 0,908 per il punteggio totale, 0,832 e      Screening version (HHIE-S-It). Acta Otorhi-
0,816 per le sue due sottoscale. È stata osservata una significativa riproducibilità (p < 0,001).       nolaryngol Ital 2023;43:262-272. https://doi.
Correlazioni moderate ed elevate sono state osservate tra l’HHIE-S-It e la soglia uditiva nell’o-       org/10.14639/0392-100X-N2297
recchio migliore (p < 0,001). Il test ANOVA ha confermato la significativa differenza dell’HHIE-
S-It in base al grado di perdita uditiva (p < 0,001). Correlazioni molto basse ma significative       © Società Italiana di Otorinolaringoiatria
                                                                                                      e Chirurgia Cervico-Facciale
sono state riportate tra l’HHIE-S-It e il PGWBI. Il criterio HHIE-S-It > 11 è risultato il miglior
cut-off per la perdita d’udito con sensibilità 86,4%, specificità 72,4%, valore predittivo positivo
                                                                                                                     OPEN ACCESS
52,8%, valore predittivo negativo 93,7%, rapporti di verosimiglianza pari a 3,12 e 0,19.
Conclusioni. Poiché l’HHIE-S-It ha presentato proprietà psicometriche e diagnostiche ac-              This is an open access article distributed in accordance with
                                                                                                      the CC-BY-NC-ND (Creative Commons Attribution-Non-
cettabili, la sua adozione è giustificata per scopi clinici e di ricerca, nonché come strumen-        Commercial-NoDerivatives 4.0 International) license. The
to di screening per la presbiacusia.                                                                  article can be used by giving appropriate credit and mentio-
                                                                                                      ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: presbiacusia, deficit uditivo, adattamento sociale, sanità pubblica,                   only in the original version. For further information: https://
apparecchi acustici                                                                                   creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                                                  Adaptation of the Hearing Handicap Inventory for Elderly




Introduction                                                       Materials and methods
Age-related hearing loss (ARHL) or presbycusis refers              Participants
to alterations of the central and peripheral auditory sys-         The study design was cross-sectional and monocentric. A
tem that occur with ageing and that lead to hearing loss           cohort of 167 consecutive outpatients attending the audio-
(HL) and difficulty in understanding spoken language. Its          logical centre at the Otorhinolaryngology Unit, Azienda
pathogenesis is complex and multifactorial. In fact, it origi-     Ospedaliero-Universitaria of Modena (Italy), were re-
nates from anatomical and functional changes, but other            cruited from May 2020 to February 2021. They all shared
contributing factors include genetic alterations, hormones,        the following minimal criteria: age ≥ 65 years, speaking
exposure to ototoxic agents or loud noises, ear or brain           Italian as their first language, willing to participate in the
infections and the presence of certain systemic diseases 1.        study, and not institutionalised or hospitalised in any health
ARHL is the most prevalent condition affecting the elderly         structures. No segregation of cases was made according to
worldwide and the leading cause of disability for individu-        type, unilateral or bilateral HL. The following exclusion
als older than 70 years 2. In Europe, it is estimated that 20%     criteria were considered: cultural barriers or presence of
to 30% of the elderly suffer from HL, defined as a hearing         major psychiatric or neurological disorders, subjects with
threshold above 30 dB, but it is impossible to establish the       fluctuating HL and balance disorders or wearing hearing
exact prevalence of presbycusis, due to the epidemiologi-          aids/cochlear implants. Thus, the recruitment process was
cal consideration of other aetiologies of HL and the het-          aimed at selecting a sample that could be representative of
erogeneity of data reported 3. However, two aspects need           the community-dwelling Italian geriatric population. The
to be considered. Firstly, it is reasonable that audiology         minimal sample size was established according to a prede-
services are predicted to be increasingly overwhelmed by
                                                                   termined respondent-to-item ratio of 10:1 13.
the increasing number of hearing-impaired elderly patients
in the future, due to the progressive ageing of the gener-
                                                                   Procedures
al population. The second is that presbycusis is strongly
                                                                   After physical examination and immittance test, tonal au-
associated with decline in cognitive functions, dementia,
                                                                   diometry was performed for each patient. The audiological
depression, and social isolation, as well as loss of commu-
                                                                   evaluation was conducted using a two-channel diagnostic
nication ability and worsening social adjustment 4. Hence,
                                                                   audiometer (INVENTIS Piano Plus, INVENTIS SRL). The
the immediate and long-term impacts on health, society
                                                                   patient was seated within a double-wall, soundproof booth
and the economy are already relevant 5. According to this
                                                                   that complies with ISO 8253 and in the window view of the
scenario, ARHL must be addressed as a public health issue
                                                                   examiner. The audiometric control board was visible only
and an early identification of hearing disorders among the
elderly is needed. Even if up to now no universal process          by the latter, who performed the evaluation following the
for screening for presbycusis exists 6, the Hearing Handi-         Hughson-Westlake method to obtain air conduction thresh-
cap Inventory for Elderly - Screening version (HHIE-S) is          olds for each ear. The pure tone average threshold (PTA)
one of the tools that can be used to determine whether a           was computed for both ears considering the four frequencies
patient has a potential HL and needs further evaluation or         (500 Hz, 1000 Hz, 2000 Hz, 4000 Hz). For statistical analy-
audiological assessment 7. It was developed from the Hear-         sis, PTA of the better ear was used. According to the degree
ing Handicap Inventory for Elderly (HHIE), an instrument           of hearing loss classification of the American Speech-Lan-
designed to quantify the effects of hearing impairment on          guage-Hearing Association (ASHA) 14, a PTA ≤ 15 dB HL
the emotional and social adjustment of elderly people 8.           means normal hearing, 16 dB HL ≤ PTA ≤ 25 dB HL slight
Although successful validation studies in the most widely          hearing loss, 26 dB HL ≤ PTA ≤ 40 dB HL mild hearing
spoken languages have been carried out, assessing psycho-          loss, 41 dB HL ≤ PTA ≤ 55 dB HL moderate hearing loss,
metric proprieties and attributes of the HHIE-S, a validated       56 dB HL ≤ PTA ≤ 70 dB HL moderately severe hearing
Italian version is not yet available 9-12.                         loss and a 71 dB HL ≤ PTA < 90 dB HL severe hearing loss,
Therefore, the first aim of the present study was to validate an   whereas a PTA over 90 dB HL represents profound hearing
Italian version of HHIE-S and to test its psychometric prop-       loss. The World Health Organization (WHO) definition of
erties in a sample of outpatients referred to audiological ser-    disabling hearing loss was considered to analyse the corre-
vices. As a second goal, we investigated whether the Italian       lations between the questionnaire and hearing function. In
version of the HHIE-S is an appropriate screening tool, fo-        particular, it refers to a PTA greater than 35 dB in the better
cusing on its attributes and the threshold that can adequately     hearing ear to separate patients with hearing disability from
discriminate normal from hearing-impaired elderly.                 those without 15.



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E. Apa et al.




Questionnaires                                                  Statistical analysis
The HHIE-S is a 10-item questionnaire that is self-admin-       All data were gathered anonymously in a Microsoft Excel®
istered by paper-and-pencil. It is composed of two 5-item       database. Statistical analysis and graphical representation
subscales that assess the self-perceived impact of hearing      were performed with the Statistical Package for Social Sci-
loss in the emotional (E) and socio-situational (S) domains     ences (IBM SPSS® version 25.0 for Microsoft Windows®).
respectively. A “yes” response to an item is awarded four       For epidemiological features, quantitative and qualitative
points, a “sometimes” two points and a “no” zero points.        variables were expressed as means with standard devia-
The score is a sum of all responses and range from 0 to 40      tions (SD) and rates, respectively. Independent t-test was
points indicating an increasing level of perceived handicap.    used to compare the continuous variables, whereas quali-
The original version of HHIE-S was translated through the       tative variables were compared using the Chi-square test.
iterative translation process that complies with the stand-     The score of the HHIE-S-It, its items, and subscales were
ards established by the International Quality of Life As-       also reported with descriptive statistics.
sessment project (IQOLA) 16, for academic use and under         In order to fulfil the HHIE-S-It validation process, it was
licence by the original Authors. Two bilingual audiologists     crucial that its psychometric proprieties were analysed 18.
translated the HHIE-S items into Italian. Conceptual equiv-     Thus, internal consistency, reliability, construct and crite-
alence, wording, comprehensiveness and feasibility of data      rion-related validity were evaluated. The internal consist-
collecting were assessed administering the provisional ver-     ency refers to the homogeneity of the questions comprising
sion to a sample of 10 healthy people. At the same time,        the questionnaire. It was assessed with Cronbach’s α coef-
the backward translation into English by two independent        ficient where higher values of α mean a greater correlation
bilingual audiologists was performed. After comparison          of item to each other (inter-item correlations). While the
of different versions obtained with the original HHIE-S,        use of cut-off is debated, in accordance with the interna-
a revision of the items was carried out. Therefore, a pre-      tional interpretation, the minimum acceptable of α is 0.7,
liminarily administration was conducted in a pilot sample       an α from 0.8 to 0.9 is considered good and an α since 0.9
of 25 hearing-impaired patients with varying educational        excellent 18. In addition, to verify if the removal of one or
and social status, in a face-to-face interview format. Since    more items from the scale improves overall α coefficient,
few doubts regarding comprehensiveness were noted,              the statistical procedure “Cronbach’s α if item is deleted”
only a minimal revision was performed and the definitive        was adopted. The reliability is essential to measure the sta-
Italian version of the Hearing Handicap Inventory for El-       bility of the scores over time. It indicates the confidence
derly – Screening version (HHIE-S-It) was obtained (Ap-         in achieving the same or similar responses if the ques-
pendix A). In order to provide evidence of criterion-related    tionnaire is distributed again to the same sample. In this
validity of the HHIE-S-It, all patients were also asked to      study, the test-retest method by comparing scores across a
complete the Italian version of the Psychological General       repeated administration to 80 selected subjects after a six-
Well-Being Index (PGWBI) 17. It is an already validated         week interval was adopted. Responders had no change in
instrument that measures the subjective perception of well-     their hearing ability and the HHIE-S-It was administered
being across six domains: anxiety, depression, positive         again in a phone-interview format. The Pearson’s correla-
well-being, self-control, general health and vitality. It is    tion coefficient and the intraclass correlation coefficient
composed of 22 items differently presented, such as state-      (ICC) were evaluated. The predetermined minimally ac-
ments or questions referring to the last four weeks of the      ceptable value was set at 0.7 for both of them. In addition,
subject’s lifetime, with responses reported on a six points     the ceiling and floor effect were calculated by percentage
Likert scale, with a score ranging from “0” to “5”. Each        frequency of highest or lowest possible score achieved by
item assesses self-representations of intrapersonal affective   respondents respectively. If present, a percentage more of
or emotional states reflecting a sense of subjective well-be-   15%, the reliability is reduced due to the difficulty in distin-
ing or distress. Response options and the scoring direction     guishing patients with the lowest or highest possible score
differ in order to inversely count answers of items regard-     from each other.
ing the distress. The items belonging to the same domain        The construct validity refers to the ability of an instrument
are balanced with respect to the direction of the responses.    to measure a theoretically derived hypothesis. Weinstein
Since each domain is defined by a minimum of three to a         et al. assumed that higher scores of HHIE-S should cor-
maximum of five items, scores for each domain range from        relate directly to the degree of hearing loss 7. In this study,
0 to 15, from 0 to 20 or from 0 to 25. The total score, ob-     Pearson’s correlation coefficient was used to disclose the
tained from the sum of all responses, can reach a maximum       presumed correlation between PTA and the total score of
of 110, representing the best achievable level of well-being.   HHIE-S-It and its subscales. The criterion-related validity



264
                                                                                                                Adaptation of the Hearing Handicap Inventory for Elderly




refers to the extent to which scores relate to a gold standard                             outcomes that are ignored in determining sensitivity. Hence,
instrument in order to assess if the total score and its sub-                              according to this limit, predictive values were also assessed,
scales were correlated with six domains of the aforemen-                                   which are functions of the target condition’s prevalence in ad-
tioned PGWBI (anxiety, depression, positive well-being,                                    dition to sensitivity and specificity. Predictive values indicate
self-control, general health and vitality). Pearson’s correla-                             the likelihood that a test can successfully identify whether
tion coefficient was used. Since HHIE-S-It measures the                                    people do or do not have hearing loss, respectively, based
increasing level of perceived hearing handicap and PGWBI                                   on their test results. In detail, the positive predictive value
measures the level of well-being, negative correlations be-                                (PPV) is the ratio of test-positive subjects truly affected by
tween the two instruments were expected. The level of sta-                                 hearing loss to the total number of patients who were posi-
tistical significance was considered reached if the p-value                                tive on the screening test. Similarly, the negative predictive
was < 0.05 in all procedures.                                                              value (NPV) is the ratio of test-negative subjects truly not
Finally, since the author proposed the HHIE-S as a screening                               affected by hearing loss to the total number of patients who
tool to detect the degree of hearing complaints 7, in the pre-                             were negative on the screening test. In addition, likelihood
sent study the predictive validity was also assessed. It refers                            ratios were assessed. In particular, the likelihood ratio for a
to the extent that it is valid to use the test score to predict the                        positive test result is the ratio of the probability of being a
presence of a target condition. Over the years, several studies                            positive screening result for patients with hearing loss to the
have evaluated the diagnostic attributes of HHIE-S in terms                                probability for those without. Similarly, the likelihood ratio
of sensitivity, specificity, predictive values and likelihood ra-                          for a negative screening test result is the ratio of the prob-
tio 9,10,12,19-21. However, most used different age populations                            ability of being a negative screening result for patients with
and different classifications of hearing loss. Thus, to analyse                            hearing loss to the probability for those without. Thus, larger
the diagnostic ability of the HHIE-S-It and its discrimination                             values for the likelihood ratio for a positive screening result
                                                                                           are more desirable, as they indicate a higher accuracy of the
threshold, a Receiver Operating Characteristics curve (ROC)
                                                                                           screening test in obtaining positive results in those with hear-
was generated. Youden’s index J was applied to calculate the
                                                                                           ing loss than in those without. Conversely, smaller values for
best cut-off for the ROC curve considering the WHO defini-
                                                                                           the likelihood ratio for a negative result are more desirable,
tion of disabling hearing loss 22. Therefore, the diagnostic
                                                                                           as they indicate a higher accuracy of the screening test in ob-
properties were evaluated considering cut-offs used in previ-
                                                                                           taining negative screening results in patients without hearing
ous studies and in present one 23. Since the target condition
                                                                                           loss than in those with hearing loss.
in our case was the presence of hearing loss, the sensitivity
and specificity are the ability to correctly identify patients
with and without hearing loss. While the former is the ratio                               Results
of patients with hearing loss and positive on the screening                                Of the 167 outpatients recruited for the study, 80 (47.9%)
test to the number of all those with hearing loss, the latter                              were males and 87 (52.1%) females. The mean age was
is the ratio of patients without hearing loss and negative on                              73.9 years (SD: 5.9; range: 65-90), whereas the mean
the screening test to the number of all those without hear-                                value of PTA was 28.4 dB nHL (SD: 15.1; range: 5-120).
ing loss. Sensitivity and specificity are intrinsic features of                            Epidemiological features of the sample are represented
the test that are related to its accuracy and remain constant                              in Table I. Considering PTA in the better ear and the
as long as the target condition and the test criterion remain                              ASHA classification of degree of hearing loss, 30 patients
constant. By themselves, however, they do not provide the                                  (17.9%) had normal hearing, 67 (40.1%) had a slight hear-
basis for informed decisions following screening test results.                             ing loss, 37 (22.2%) had a mild hearing loss, 26 (15.6%)
In fact, positive test results could contain many false positive                           had a moderate hearing loss, 7 (4.2%) had a moderately
outcomes that are ignored in determining sensitivity. Simi-                                severe hearing loss. No participant had a severe or pro-
larly, negative test results could contain many false negative                             found hearing loss (Fig. 1). Males were not significantly


Table I. Epidemiological features of the sample.
 Variable                              Total (n = 167)                                         Male (n = 80)                                  Female (n = 87)
                               Mean            SD             Min-max             Mean           SD            Min-max             Mean           SD       Min-max
 Age (years)                   73.9            5.9              65-90              74.8          5.7             65-90              73.1          5.9           65-90
 PTA (dB HL)                   28.4           15.1              5-120              31.5         18.2           6.5 - 120            25.5         11.9           5-55
SD: standard deviation; min-max: lowest and highest values; PTA: pure tone average threshold (500 Hz, 1000 Hz, 2000 Hz, 4000 Hz) in the better ear.




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E. Apa et al.




Figure 1. Distribution of hearing loss in the sample based on PTA according to the ASHA’s degree of hearing loss. Normal hearing: from -15 to 15 dB HL (30
subjects, 18.0%); Slight hearing loss: from 16 to 25 dB HL (67 subjects, 40.1%); Mild hearing loss: from 26 to 40 dB HL (37 subjects, 22.2%); Moderate hearing
loss: from 41 to 55 dB HL (26 subjects, 15.6%); Moderately severe hearing loss: from 56 to 70 dB HL (7 subjects, 4.2%); Severe hearing loss: from 71 to 90 dB HL
(0 subjects, 0.0%); Profound hearing loss: from 91 dB HL (0 subjects, 0.0%).



older than females (t = 1.883, df = 164.6, p = 0.061), but                                    0.832 and 0.816 for the E and S subscales respectively. In
the degree of hearing loss in the better ear was signifi-                                     the procedure “Cronbach’s α if item is deleted”, removal
cantly worse in males (t = 2.504, df = 134.1, p = 0.013).                                     of item 6 improved overall α coefficient of the total score
The score of the HHIE-S-It and its subscales are reported                                     to 0.916 and of the S scale to 0.854. After its removal,
by descriptive statistics in Table II. No significant differ-                                 no other item increased α again. The Pearson’s correla-
ence was found between genders regarding the HHIE-S-It                                        tion coefficient ρ between the total scores of the HHIE-
total score (t = 1.486, df = 152.1, p = 0.139), the S score                                   S-It and its subscales was 0.965 for the E subscale (2-tail
(t = 1.830, df = 160.2, p = 0.069) and E score (t = 1.719,                                    significance < 0.001) and 0.967 for the S subscale (2-tail
df = 156.4, p = 0.088).                                                                       significance < 0.001) respectively. A significant correla-
                                                                                              tion between the two subscales was identified also: the ρ
Internal consistency and reliability                                                          was 0.867 (2-tails significance < 0.001). The test-retest
Cronbach’s α coefficient was 0.908 for the total score, and                                   reliability of HHIE-S-It and its subscales, evaluated by


Table II. Total score of the HHIE-S-It and scores of its Emotional (E) and Socio-Situational (S) subscales.
 Scale                                       Total (n = 167)                              Male (n = 80)                                             Female (n = 87)
                                        Mean           SD           Min-max             Mean            SD           Min-max             Mean            SD           Min-max
 HHIE-S-It (Total)                      12.2          11.7            (0-38)             13.9          12.5            (0-38)             10.7          10.7            (0-38)
 HHIE-S-It (E)                          5.5           5.9             (0-20)              7.6           6.4            (0-20)              4.8          5.3             (0-20)
 HHIE-S-It (S)                           6.7           6.2            (0-20)              6.2           6.5            (0-20)              5.9           5.8            (0-20)
HHIE-S-It: Italian version of the Hearing Handicap Inventory for Elderly – Screening version; SD: standard deviation; min-max: lowest and highest values; E: emotional subscale of the
HHIE-S-It; S: socio-situational subscale of the HHIE-S-It; Total: total score of the HHIE-S-It.




266
                                                                                                                        Adaptation of the Hearing Handicap Inventory for Elderly




Table III. The test-retest reliability of HHIE-S-It and its subscales.
 Scale                                                                               ICC, Mean (95% CI), 2-tail significance                                             ρ
    HHIE-S-It (Total)                                                                       0.731, (0.580-0.827), 0.000                                         0.576 (< 0.001)
    HHIE-S-It (E)                                                                           0.542, (0.285-0.706), 0.000                                         0.372 (< 0.001)
    HHIE-S-It (S)                                                                           0.442, (0.129-0.642), 0.005                                         0.284 (< 0.001)
HHIE-S-It: Italian version of the Hearing Handicap Inventory for Elderly – Screening version; SD: standard deviation; min-max: lowest and highest values; E: emotional subscale of
the HHIE-S-It; S: socio-situational subscale of the HHIE-S-It; Total: total score of the HHIE-S-It; ICC: intraclass correlation coefficient; CI: Confidence Interval; ρ: Pearson’s correlation
coefficient.




the ICC and Pearson’s correlation coefficient, was found                                          scale and the Vitality of the PGWBI (p < 0.005), between
to be correlated at a significant level as shown in Table III.                                    the E score and Vitality domain (p < 0.05), and between
The floor effect was 21.6%, 33.5%, 23.9% for total score                                          the three scores of the HHIE-S-It and Self-Control domain
of the HHIE-S-It, E and S subscales respectively, while                                           (p < 0.05). Moreover, significant correlations were seen be-
the ceiling effect was 2.9%, 2.4%, 2.9% for the three dif-                                        tween total score and S subscale of the HHIE-S-It and the
ferent scores.                                                                                    total score of the PGWBI (p < 0.05).

Construct validity                                                                                Predictive validity
Pearson’s correlation coefficient between PTA in the bet-                                         In the sample of the present study, the prevalence of disa-
ter ear and HHIE-S-It total score was 0.628 (2-tail signifi-                                      bling hearing loss was 26.3%. The ROC curve showed
cance < 0.001). Highly significant correlations were also                                         an AUC of 0.860, which is significantly higher than
identified between PTA and the E and S subscales of the                                           (p < 0.001) chance, i.e. AUC = 0.5 (Fig. 3). The Youden in-
HHIE-S-It: ρ was 0.544 (2-tail significance < 0.001) and                                          dex J was 0.587 and the associated criterion was HHIE-S-It
                                                                                                  total score > 11, corresponding to a sensitivity of 86.4%
0.643 (2-tail significance < 0.001) respectively. As con-
                                                                                                  and a specificity of 72.4%. PPV and NPV were 52.8% and
firmed by the one-way ANOVA test, the HHIE-S-It total
                                                                                                  93.7%, respectively. LR+ was 3.12 whereas LR- was 0.19.
score (F = 26.3; p < 0.001) and scores of its two subscales
                                                                                                  According to previous studies, a criterion of HHIE-S-It to-
(F = 19.1; p < 0.001 for E; F = 29.5; p < 0.001 for S) were
                                                                                                  tal score > 8 was considered 7,9,10,12,19,21. In this case, a sen-
significantly higher according to degree of hearing loss
                                                                                                  sitivity of 86.4% and a specificity of 67.7% were observed.
(Fig. 2).                                                                                         PPV and NPV were 49.4% and 93.3%, respectively. LR+
                                                                                                  was 2.68 and LR- was 0.20.
Criterion-related validity
Negative correlations were found between the HHIE-S-It
and its subscales (S, E) scores and all domain scores of                                          Discussion
the PGWBI (Tab. IV). In particular, significant correlations                                      In this study, 167 elderly outpatients were recruited in
were identified between the HHIE-S-It total score, S sub-                                         accordance with the predetermined respondent-to-item


Table IV. Correlations between the HHIE-S-It, its subscales and the PGWBI domains scores.
                                                                                                              PGWBI
                                             Anxiety            Depression            Positiveness          Self-Control            General               Vitality              Total
                                                                                                                                    Health

    HHIE-IT (Total)           ρ               -0.095               -0.100                 -0.130                -0.191*              -0.039               -0.219**             -0.159*
                        Sig. (2-tails)      p = 0.221            p = 0.201              p = 0.094             p = 0.013            p = 0.615            p = 0.004            p = 0.040
    HHIE-IT (E)               ρ               -0.082               -0.091                 -0.108               -0.196*               -0.260              -0.184*               -0.140
                        Sig. (2-tails)      p = 0.291            p = 0.243              p = 0.164             p = 0.011            p = 0.735            p = 0.017            p = 0.072
    HHIE-IT (S)               ρ               -0.101               -0.101                 -0.142               -0.174*               -0.049              -0.239**             -0.167*
                        Sig. (2-tails)      p = 0.192            p = 0.193              p = 0.066             p = 0.024            p = 0.530            p = 0.002            p = 0.031
*
 : p < 0.05; **: p < 0.005.
HHIE-S-It: Italian version of the Hearing Handicap Inventory for the Elderly – Screening version; E: emotional subscale of the HHIE-S-It; S: socio-situational subscale of the HHIE-S-It;
Total: total score of the HHIE-S-It; PGWBI: Psychological General Well-Being Index; ρ: Pearson’s correlation coefficient.




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Figure 2. Distribution of HHIE-S-It total score according to the degree of hearing loss based on the ASHA classification. Normal hearing: from -15 to 15 dB HL
(n = 30); Slight hearing loss: from 16 to 25 dB HL (n = 67); Mild hearing loss: from 26 to 40 dB HL (n = 37); Moderate hearing loss: from 41 to 55 dB HL (n = 26);
Moderately severe hearing loss: from 56 to 70 dB HL (n = 7); Severe hearing loss: from 71 to 90 dB HL (n = 0); Profound hearing loss: from 91 dB HL (n = 0).
The HHIE-S-It total score was significant higher according to degree of hearing loss. The one-way ANOVA test confirmed the difference between the HHIE-S-It total
score, the E score and the S score within the five groups (p < 0.001).



ratio of 10:1 13. Only subjects aged 65 years or older with-                       α coefficient was 0.908 for the total score, and 0.832 and
out hearing aids or cochlear implants were considered.                             0.816 for the E and S subscales, respectively. Table V
While males were not significantly older than females                              compares the internal consistency in present study with
(p = 0.061), the degree of HL in the better ear was signifi-                       that observed in other validation studies 10-12. Only the re-
cantly worse in males (p = 0.013). Since the prevalence of                         moval of item 6 slightly improved the α coefficient of the
the HL is nearly twice in males, this result was not sur-                          total score and S subscale (0.916 and 0.854). This item
prising 21. However, no significant differences were found                         “Does a hearing problem cause you to attend religious
between sex regarding the score of HHIE-S-It and S and                             services less often than you would like?” investigates as-
E subscales (p = 0.139; p = 0.069; p = 0.088). Hence, the                          pects most complained about by elderly hearing-impaired
statistical analysis was conducted considering the entire                          patients, such as speech perception in competing back-
sample regardless of gender. According to the ASHA’s HL                            ground noise, deteriorated signal and challenging social
degree classification 14, 137 (82%) subjects presented HL                          environments. Moreover, as observed during preliminary
but most, 130 (77.8%), had slight to moderate HL. None                             administration, patients were inclined to misunderstand
had severe or profound HL. Differently, considering the                            the question, answering based on their usual attendance at
actual definition of the WHO 15, the prevalence of disa-                           religious services. Nevertheless, according to Ventry and
bling HL was 26.3% (44 subjects). This discrepancy gives                           Weinstein, it is “necessary and desirable” to identify all
an idea of how the use of different types of definitions and                       specific situations that could be detrimental to social ad-
classifications influences the epidemiological data of the                         aptation, although not so frequently encountered by older
ARHL.                                                                              people in their everyday life 8. Hence, considering these
Other validation studies considered psychometric proper-                           aspects and the slight improvement of Cronbach’s α coef-
ties 11, attributes as screening tool 9 or both 10,12. The inter-                  ficient, item 6 was not removed from the HHIE-S-It. A
nal consistency was good to excellent since Cronbach’s                             floor effect was observed for HHIE-S-It and its subscales



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Table V. The internal consistency of HHIE-S-It total score in the present and other validation studies.
                                                        Present study               Tomioka et al. 10                             Öberg 11                 Duchêne et al. 12


 Cronbach’s α coefficient                                          0.908                              0.92                          0.77                          0.84
 Test-retest reliability (ICC, 95% CI)                             0.731                              0.85                            -                             -
                                                               (0.580-0.827)                      (0.81-0.89)
HHIE-S-It: Italian version of the Hearing Handicap Inventory for Elderly – Screening version; SD: standard deviation; min-max: lowest and highest values; E: emotional subscale of the
HHIE-S-It; S: socio-situational subscale of the HHIE-S-It; Total: total score of the HHIE-S-It; ICC: intraclass correlation coefficient; CI: Confidence Interval.




whereas no ceiling effect was reported. This could lead to                                    correlate directly with the degree of HL 7. In the present study,
difficulty in distinguishing patients with the lowest possi-                                  very high correlations between the total score and S and E
ble scores and may be considered a slight limit. The test-                                    and between the two subscales were observed (p < 0.001). In
retest reliability was used to measure the reproducibility                                    addition, moderate to high correlations were found between
of the instrument. It was adequate since a significant ICC                                    PTA in the better ear and HHIE-S-It (p < 0.001) and between
and Pearson’s correlation coefficient were found between                                      PTA and the two subscales (p < 0.001). The ANOVA test
the HHIE-S-It and its subscales (Tab. III).                                                   confirmed the significant difference in HHIE-S-It scoring
Ventry and Weinstein developed the HHIE-S to measure                                          across groups according to ASHA’s HL degree classifica-
hearing disability. They assumed that higher scores should                                    tion (p < 0.001). Figure 2 shows this difference graphically.
                                                                                              These observations confirmed the construct validity of the
                                                                                              instrument. The criterion-related validity was also assessed
                                                                                              administering in addition the PGWBI, an already validated
                                                                                              instrument. Since the HHIE-S-It measures the increasing
                                                                                              level of perceived hearing handicap and PGWBI measures
                                                                                              the level of well-being, negative very low and low signifi-
                                                                                              cant correlations were observed between HHIE-S-It and Self
                                                                                              Control (p < 0.05), HHIE-S-It, S and Total score of PGWBI
                                                                                              (p < 0.05), HHIE-S-It, S and Vitality (p < 0.005), E and Vital-
                                                                                              ity (p < 0.05). This shows that if quality of life needs to be
                                                                                              considered, a specific questionnaire should be given in addi-
                                                                                              tion to the HHIE-S-It.
                                                                                              Since the HHIE-S is intended as a screening tool 6, several
                                                                                              studies have evaluated the diagnostic attributes 9,10,12,19‑21.
                                                                                              Most used different age populations and different clas-
                                                                                              sifications of HL 21. Lichtenstein et al. were among the
                                                                                              first to evaluate the diagnostic performance of the HHIE-S
                                                                                              by considering different definitions of HL 19. They codi-
                                                                                              fied the presence of hearing disability according to the
                                                                                              instrument scoring. A score from 0 to 8 was considered
                                                                                              indicative of no hearing handicap, from 10 to 24 of mild
                                                                                              to moderate handicap, and a value from 26 to 40 indica-
                                                                                              tive of severe handicap. Subsequently, scores above 8 be-
                                                                                              came indicative of the presence of hearing impairment,
                                                                                              and the diagnostic properties of the instrument, even in
Figure 3. The ROC curve of the HHIE-S-It. The Receiver Operating Char-
                                                                                              other validation studies 9,10,12, were analysed by consider-
acteristics curve shows the diagnostic ability of the HHIE-S-It total score in                ing a cut-off > 8. However, the WHO recently changed
detecting the hearing loss, in term of true-positive rate (sensitivity) and false-            the definition of disabling HL to the presence of a PTA
positive rate (1 - specificity). The Youden index J is the point where the ROC                greater than 35 dB in the better hearing ear 15. Thus, in the
curve is at maximum distance from the no discrimination line (chance line).
It represents the HHIE-S-It value with the highest test accuracy. The World
                                                                                              present study the actual WHO definition was considered.
Health Organization (WHO) definition of disabling hearing loss was considered                 The ROC curve and Youden’s index J were applied to cal-
to elaborate the ROC curve.                                                                   culate the best cut-off for the HHIE-S-It. The criterion to-



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E. Apa et al.




tal score > 11 was observed as the best cut-off with high-
est sensitivity (86.4%), specificity (72.4%), PPV (52.8%),
NPV (93.7%), LR+ (3.12) and LR- (0.19). In addition, the
diagnostic properties of the criterion total score > 8 were
analysed and were found to be smaller.
While many years have passed and different classifications
of the degree of HL have emerged, Figure 4 shows that the
HHIE-S-It with criterion total score > 11 has diagnostic
properties comparable to those of the original and most
widely spoken language versions. In fact, the HHIE-S-It
presented Likelihood ratios (LRs) comparable to those ob-
served in other studies. Tomiaka et al. 10 reported LR+ and
LR- equal to 3.60 and 0.20 considering hearing loss as a
PTA greater than 40 dB in the better ear and LR+ and LR-
equal to 2.90 and 0.70 considering hearing loss as a PTA
greater than 25 dB in the better ear. Servidoni and Conter-
no 20 reported a LR+ and LR- of 3.56 and 0.15 considering
hearing loss as a PTA greater than 40 dB in the better ear.
Furthermore, some aspects need to be taken into considera-
tion. The AUC of 0.860 indicated a very good diagnostic
accuracy. The observed LRs indicated that HHIE-S-It could
                                                                 Figure 4. Diagnostic proprieties of different versions of the Hearing Handi-
be considered a valid screening tool 24. Indeed, screening       cap Inventory - Screening Version (HHIE-S). For the Italian version (HHIE-S-It)
tests typically should present some advantages compared          the criterion was total score > 11 whereas for the other version the criterion
to diagnostic tests, such as involving less load on the health   was total score > 8. Different definitions of hearing loss were used among the
                                                                 studies. °Pure Tone Average > 35 dB in the better ear; °°Hearing threshold at
care system, being more affordable and available, as well        1000 and 2000 Hz > 40 dB in the better ear or both ears; ▪Hearing thresh-
as less invasive, less dangerous, less time-consuming, and       old at 500, 1000 and 2000 Hz > 25 dB in the better ear; ••Pure Tone Aver-
less uncomfortable for patients 23. Screening tests are also     age > 40 dB in the better ear; •Pure Tone Average > 25 dB in the better ear;
                                                                 ※
well-known for being imperfect and sometimes ambigu-              Pure Tone Average > 20 dB in one or both ears; PPV, positive predictive value;
                                                                 NPV, negative predictive value.
ous. Hence, sensitivity and specificity should be considered
appropriated as comparable to HHIE-S and its most widely
spoken language versions. Predictive values should be con-
sidered appropriated in addition. In particular, the moderate    hearing loss degree classification. Cronbach’s α coefficient
PPV (52.8%) might be acceptable since that diagnostic test       was excellent for the total score and good for its two sub-
is easily and quickly performed, and not stressful, expen-       scales. While test-retest reliability and construct validity
sive, or unavailable 23. Furthermore, a high NPV might be        were acceptable, the criterion-related validity showed only
acceptable because ARHL is a serious, often asymptomatic         very weak to weak correlations with some domains of an
or underestimated issue that can be treated effectively sav-     instrument that measures the level of well-being. The AUC,
ing large amounts of public financial resources 25.              sensitivity, specificity, predictive values and likelihood ra-
Finally, two limitations should be taken into account.           tios demonstrated that for the HHIE-S-It the criterion total
The floor effect observed could lead to a difficulty in dis-     score > 11 is the best cut-off to separate patients with hear-
tinguishing patients with the lowest possible scores. The        ing disability from those without. Therefore, the HHIE-S-It
HHIE-S-It cannot provide any information about the out-          was found to be a valid instrument with acceptable psy-
come of hearing aids since no patient was wearing them in        chometric properties that allow its use for both clinical and
our sample.                                                      research purposes for Italian-speaking subjects. In the same
                                                                 way, the diagnostic attributes were found to be acceptable
                                                                 enough to allow its use as a screening tool according to
Conclusions                                                      the uses recommended by current guidelines 6. In order to
In the current study, we translated and validated the Italian    properly interpret the results, clinicians need to be aware
version of the HHIE-S (HHIE-S-It). Psychometric proprie-         that the criterion is total score > 11 and that the instrument
ties and diagnostic attributes were assessed properly in a       cannot provide any information about the outcome of hear-
sample of 167 elderly outpatients considering the current        ing aids.



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                                                                                           Adaptation of the Hearing Handicap Inventory for Elderly




Acknowledgements                                                             sion: a scoping overview. Semin Hear 2021;42:10-25. https://
The authors thank Franca Laura Artioli, Mariagrazia To-                      doi.org/10.1055/s-0041-1725997
taro, Patrizia Cardini, Paola Allegra and Francesco Ostello,
                                                                        5    The World Health Organization. Global costs of unaddressed
                                                                             hearing loss and cost-effectiveness of interventions: a WHO re-
audiometric technicians of the Operative Unit of Otolar-                     port, 2017. Geneve: The World Health Organization; 2017.
yngology, Azienda Ospedaliero-Universitaria di Modena,                  6    Gurgel RK, Briggs SE, Dhepyasuwan N, et al. Quality improve-
Modena, Italy, for their contribution in performing audio-                   ment in otolaryngology-head and neck surgery: age-related hear-
metric evaluations.                                                          ing loss measures. Otolaryngol Head Neck Surg 2021;165:765-
                                                                             774. https://doi.org/10.1177/01945998211000442
Conflict of interest statement
                                                                        7    Ventry IM, Weinstein BE. Identification of elderly people with
                                                                             hearing problems. ASHA 1983;25:37-42.
The authors declare no conflict of interest.                            8    Ventry IM, Weinstein BE. The hearing handicap inventory for
                                                                             the elderly: a new tool. Ear Hear 1982;3:128-134. https://doi.
Funding                                                                      org/10.1097/00003446-198205000-00006
Internal departmental funding was used to support this                  9    Salonen J, Johansson R, Karjalainen S, et al. Relationship be-
study without commercial sponsorship. This research re-                      tween self-reported hearing and measured hearing impairment
ceived no other specific grant from any funding agency in                    in an elderly population in Finland. Int J Audiol 2011;50:297-
                                                                             302. https://doi.org/10.3109/14992027.2010.549517
the public, commercial, or not-for-profit sectors.
                                                                        10   Tomioka K, Ikeda H, Hanaie K, et al. The hearing handicap in-
                                                                             ventory for elderly-screening (HHIE-S) versus a single question:
Author contributions                                                         reliability, validity, and relations with quality of life measures
EA: investigation, data curation, formal analysis, visualiza-                in the elderly community, Japan. Qual Life Res 2013;22:1151-
tion, writing – original draft; LS: supervision, writing – re-               1159. https://doi.org/10.1007/s11136-012-0235-2
view and editing; SP: methodology, conceptualization, su-               11   Öberg M. Validation of the swedish hearing handicap inventory for
                                                                             the elderly (screening version) and evaluation of its effect in hear-
pervision, writing – review and editing; CC: investigation,
                                                                             ing aid rehabilitation. Trends Hear 2016;20:2331216516639234.
data curation, writing – original draft; CG: investigation,                  https://doi.org/10.1177/2331216516639234
data curation; EG: methodology, resources; DM: method-                  12   Duchêne J, Billiet L, Franco V, et al. Validation of the french
ology, project administration, supervision, writing – review                 version of HHIE-S (hearing handicap inventory for the elderly -
and editing; RN: validation, visualization, writing – review                 screening) questionnaire in french over-60 year-olds. Eur Ann
                                                                             Otorhinolaryngol Head Neck Dis 2022;139:198-201. https://doi.
and editing.
                                                                             org/10.1016/j.anorl.2021.11.003
                                                                        13   Nunnally JC. Psychometric theory. Second edition. New York:
Ethical consideration                                                        McGraw-Hill; 1978.
The study was approved by the local Ethics Committee                    14   Clark JG. Uses and abuses of hearing loss classification. ASHA
(Protocol AOU 0012599/20 of 6th May 2020). All proce-                        1981;23:493-500.
dures performed were in accordance with the ethical stand-              15   The World Health Organization. Deafness and Hearing Loss
ards of the institutional research committee and with the                    (https://www.who.int/news-room/fact-sheets/detail/deafness-
1964 Helsinki declaration and its later amendments.                          and-hearing-loss, accessed on 12/8/2022).
Written informed consent was obtained from each partici-
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