10.14639/0392-100X-N2116
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 &gt; 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.
text/xml
1827-675X
2116
en
Daniele Monzani
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
fatigue
Validity of the Italian adaptation of the Hearing Handicap Inventory for the Elderly (HHIE-It)
Text.Serial.Journal
https://www.actaitalica.it/
43
Otology
2023-02-27
2022-04-06
2023-02-28
2023-02-28
74-81
1
Daniele Monzani
2023/02/27
10.14639/0392-100X-N2116
74
Department of Medical and Surgical Sciences for Children and Adults, Otorhinolaryngology Unit, Azienda Ospedaliero-Universitaria of Modena, University of Modena and Reggio Emilia, Modena, Italy; Present address: Head and Neck Department, University of Verona, Unit of Otolaryngology, Borgo Roma Hospital, Verona, Italy
1827-675X
fatigue
en
81
Validity of the Italian adaptation of the Hearing Handicap Inventory for the Elderly (HHIE-It)
https://www.actaitalica.it/article/download/2116/921
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:74-81; doi: 10.14639/0392-100X-N2116




Otology


Validity of the Italian adaptation of the Hearing
Handicap Inventory for the Elderly (HHIE-It)
Validazione dell’adattamento in lingua italiana dell’Hearing Handicap Inventory
for the Elderly (HHIE-It)
Federica Di Berardino1, Riccardo Nocini2, Brigitta Ariotti1, Enrico Apa3, Chiara Gherpelli3, Daniele Monzani3*
1
  Audiology Unit, Department of Specialist Surgical Sciences, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan,
Italy; 2 Head and Neck Department, University of Verona, Unit of Otolaryngology, Borgo Roma Hospital, Verona, Italy; 3 Department
of Medical and Surgical Sciences for Children and Adults, Otorhinolaryngology Unit, Azienda Ospedaliero-Universitaria of Modena,
University of Modena and Reggio Emilia, Modena, Italy
*
  Present address: Head and Neck Department, University of Verona, Unit of Otolaryngology, Borgo Roma Hospital, Verona, Italy


SUMMARY
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 consist-
ency, 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              Received: April 6, 2022
suggesting its utility for both clinical and research purposes.                                      Accepted: July 26, 2022

KEY WORDS: hearing loss, quality of life, disability, fatigue                                        Correspondence
                                                                                                     Daniele Monzani
RIASSUNTO                                                                                            Head and Neck Department, University of Verona,
Obiettivo. Lo scopo di questo studio è stato quello di valutare la validità e l’affidabilità della   Unit of Otolaryngology, Borgo Roma Hospital,
                                                                                                     p.le L.A. Scuro 10, 37134 Verona, Italy
traduzione italiana del questionario Hearing Handicap Inventory for the Elderly (HHIE).
                                                                                                     Tel: +39 045 8128332. Fax +39 045 8122070
Metodi. Un campione di 275 pazienti ambulatoriali di età maggiore di 65 anni ha compi-
                                                                                                     E-mail: daniele.monzani@aovr.veneto.it
lato la versione italiana dell’HHIE (HHIE-It) insieme al questionario MOS 36-Item Short
Form Health Survey (SF-36). Settantuno partecipanti hanno risposto al questionario una
seconda volta a mezzo di intervista telefonica.                                                        How to cite this article: Di Berardino F, No-
Risultati. Il coefficiente alfa di Cronbach è risultato 0,941 suggerendo un’elevata coerenza           cini R, Ariotti B, et al. Validity of the Ital-
interna. Il coefficiente di correlazione intraclasse e il coefficiente di Pearson sono risultati       ian adaptation of the Hearing Handicap In-
statisticamente significativi nel test-retest. Inoltre, si sono evidenziati coefficienti di corre-     ventory for the Elderly (HHIE-It). Acta
                                                                                                       Otorhinolaryngol Ital 2023;43:74-81. https://
lazione significativi tra il punteggio totale dell’HHIE-It e la soglia audiometrica dell’orec-
                                                                                                       doi.org/10.14639/0392-100X-N2116
chio migliore e tra l’HHIE-It e le sottoscale Ruolo-Emotivo, Funzionamento Sociale e Vi-
talità del questionario SF-36, quale espressione di buona validità di costrutto e di criterio.
                                                                                                     © Società Italiana di Otorinolaringoiatria
Conclusioni. L’HHIE-It ha mantenuto pertanto l’affidabilità e la validità della versione             e Chirurgia Cervico-Facciale
originale in lingua inglese suggerendo il suo utilizzo sia per scopi clinici che di ricerca.
                                                                                                                    OPEN ACCESS
PAROLE CHIAVE: ipoacusia, qualità della vita, disabilità, fatica
                                                                                                     This is an open access article distributed in accordance with
                                                                                                     the CC-BY-NC-ND (Creative Commons Attribution-Non-
Introduction                                                                                         Commercial-NoDerivatives 4.0 International) license. The
                                                                                                     article can be used by giving appropriate credit and mentio-
                                                                                                     ning the license, but only for non-commercial purposes and
Population aging is defined as the progressive lengthening of life expectancy                        only in the original version. For further information: https://
associated with an increasing number of elderly persons in any population. The                       creativecommons.org/licenses/by-nc-nd/4.0/deed.en




74
                                                        Correlations between perceived hearing disability in the elderly and a quality-of-life survey




economic effects of increased population ageing are con-              were established: both genders, age > 65 years, speaking
siderable and new challenges to health care systems should            Italian as their first language and willing to participate in
be considered. In fact, there were 727 million people aged            the study. No segregation of cases was made on the basis of
65 years or above (9.3% of the total world population) in             type of hearing loss (conductive, sensorineural and mixed).
2020 and this number is expected to consistently increase             Patients with unilateral or bilateral loss of hearing were
to about 1.5 billion or approximately 16% of the total world          both invited to participate. The following exclusion crite-
population by the year 2050 according to the United Na-               ria were established. Firstly, the presence of major neuro-
tions 1. Age-related hearing loss (ARHL), or presbycusis, is          logical or psychiatric disorders or any other morbidity that
one of the most common conditions affecting older adults              could prevent them from understanding and answering the
and is the third most prevalent chronic condition after hy-           self-administered questionnaires by paper and pencil. Pa-
pertension and arthritis. Since population ageing is the most         tients with cultural barriers that could prevent them from
significant predictor of hearing loss, it is not surprising that      understanding the questionnaire items were excluded. Fur-
nearly one of four individuals aged 65 to 74 and one of two           thermore, subjects with fluctuating hearing loss and bal-
of those 75 and older are affected 2,3. Taken these epidemio-         ance disorders, or wearing hearing aids/cochlear implants
logical data together, audiological services are expected to          were not included.
be increasingly overwhelmed with older patients with hear-
ing loss in the future. One of the most intriguing questions          Procedures
arising from this scenario is the methodology that should             After otoscopic examination and immittance audiometry,
be considered the most appropriate to fully assess hearing            each patient was seated within a double-wall, sound booth
loss disability and handicap in older people. Hearing loss is         that complies with ISO 8253 and in the window view of
a barrier to communication and easily gives origin to a cas-          the examiner but not of the audiometric controls board.
cade of relevant consequences such as withdrawal from so-             Audiological screening of each subject was carried out us-
cial interaction, depression and increased risk for cognitive         ing a Type 1 two-channel diagnostic audiometer (MAD-
decline 4. If audiometric measures alone directly reflect the         SEN Astera 1066 type, GN Otometrics A/S) and managing
magnitude of sensory deprivation, the difficulties encoun-            data using integrated OTO suite software. The examiners
tered by the listener in daily real-life, their consequences          followed the Hughson-Westlake method of obtaining air
on social attitudes and psychological well-being need more            conduction thresholds for each ear. The four frequency
exhaustive tools. Ventry and Weinstein, after investigating           (0.5 KHz, 1 KHz, 2 Khz, 4 KHz) pure tone average thresh-
and carefully analysing other research on this topic, devel-          old (4fPTA) was computed for both ears and then the bet-
oped a new, self-assessment tool designed to quantify the             ter ear 4fPTA of each participant was used for statistical
effects of hearing impairment on the emotional and social             analysis. According to the WHO’s Grades of hearing im-
adjustment to hearing loss in elderly people: the Hearing             pairment 13, a 4fPTA ≤ 25 dB HL means no impairment,
Handicap Inventory for the Elderly (HHIE) 5. The origi-               26 dB HL ≤ 4fPTA ≤ 40 dB HL mild impairment, 41 dB
nal English version of this questionnaire was found to be             HL ≤ 4fPTA ≤ 55 dB HL suggests moderately-severe im-
valid and reliable 5,6. Its translations have been carried out        pairment, 56 dB ≤ 4fPTA ≤ 70 dB indicates severe impair-
across different countries and cultures 7-11. To our knowl-           ment and a 71 dB HL ≤ 4fPTA < 90 dB HL represents pro-
edge, since no study has adapted it to the Italian language,          found impairment.
the aim of the present study is to validate an Italian version
of the questionnaire (HHIE-It) and test its psychometric              Questionnaires
properties in a sample of community-dwelling older adults.            As is the original English version of the HHIE, the Ital-
                                                                      ian translation is 25-item questionnaire (HHIE-It) that is
                                                                      comprised of two subscales: a 13-item subscale explores
Materials and methods                                                 the emotional consequences of hearing impairment (E); a
Study population                                                      12-item subscale explores both social and situational ef-
A cohort of 275 subjects was recruited for this study from            fects (S) (Appendix I). A NO answer to an item is awarded
May 2018 to June 2019. This sample size was adopted in                0 points, SOMETIMES 2 points and YES 4 points. The pos-
accordance with a predetermined respondent-to-item ratio              sible scores of E and S are between 0 and 52 and 0 and 48,
of 10:1 12. The subjects were consecutive outpatients attend-         respectively. Therefore, the total score ranges from 0 to 100
ing the audiological centre at the Audiology Unit, IRCCS              points, with higher scores indicating a greater level of per-
Fondazione Policlinico, Mangiagalli e Regina Elena, Uni-              ceived handicap. The original version was translated using
versity of Milan (Italy). The following inclusion criteria            a forward and backward technique that complies with the



                                                                                                                                                 75
F. Di Berardino et al.




standards established by the IQOLA (International Quality         item is deleted” was adopted. This procedure is intended to
of Life Assessment) project 14, for academic use and under        verify if the removal of one or more items from the scale
license by the original authors. Before starting the present      improves the overall α coefficient. HHIE-It was adminis-
study, the HHIE-It was preliminarily administered in a pilot      tered a second time to 71 selected subjects who responded
sample of 28 hearing-impaired patients with varying educa-        with no change in their hearing ability after a six weeks
tional and social status, in a face-to-face interview format.     interval in a phone-interview format to assess test-retest
Since few doubts about wording and comprehensiveness              consistency. This is essential to measure the stability of the
occurred, only a minor revision of the items was carried          scores over time and comparison was made by calculating
out. In order to provide evidence of criterion-related valid-     both the Pearson’s correlation between the two surveys and
ity for HHIE-It, all patients were also asked to complete         the ICC. In this study, ICC estimates and their 95% confi-
the Italian version 15 of an existing and already validated in-   dent intervals were calculated based on single measures,
strument that measures the psycho-sociological domains of         absolute-agreement and a 2-way mixed-effects model. The
health-related quality of life, the MOS 36-Item Short Form        predetermined, minimally acceptable ICC value was set at
Health Survey (SF-36) 16. This questionnaire investigates         0.8. Construct validity of the HHIE-It refers to the ability
health status in the past four weeks on eight subscales:          of a survey to measure an intended hypothetical construct.
general health, physical functioning, role-physical, bodily       It was assumed that higher scores of HHIE-It and its sub-
pain, vitality, social functioning, role-emotional and men-       scales should directly correlate to the degree of hearing
tal health. Each dimension is separately scored using item        loss. We used Pearson’s correlation coefficient to disclose
weighting and additive scaling. Summed data were then             the presumed correlation between 4fPTA (dB HL) and the
transformed into a 0 to 100-point scale with higher score         total score of HHIE-It and its subscales. As already men-
indicating better condition. Similar to a previous validation     tioned, the Italian version of the MOS 36-Item Short Form
study of the Hearing Handicap Inventory for Adults 17, we         Health Survey (SF-36) 15 was employed to assess criterion-
employed the social-functioning (SF) and the role-emo-            related validity of the questionnaire and its subscales. The
tional (RE) subscales as analogues of the correspondent S         HHIE-It total score was correlated to the vitality (V) sub-
and E subscales of the HHIE-It. The SF subscale evaluates         scale score of the SF-36, whereas the S and E subscales
the impact of physical and emotional problems on social           scores were correlated to the social functioning (SF) and
activities (with family, friends, neighbours and groups),         the role-emotional (RE) subscales of the same question-
while the RE rates the interference of emotional problems         naire, respectively. Pearson’s correlation coefficient was
(such as feeling depressed or anxious) with regular daily         used. Finally, ceiling and floor effects were computed and
activities. In the framework of this work, we also used the       considered present if more that 15% of the patients re-
subscale ‘vitality’ (V) of the SF-36. This subscale is gen-       ported the minimum (0) or the maximum (100) score of
erally accepted to be a valid measure of energy/fatigue 18.       the scale 21. Significance was considered if the p-value was
As a fact, increasing evidence from audiological medicine         < 0.05. Data analysis was performed using the Statistical
suggests that fatigue, as opposed to vigour and energy, is a      Package for Social Sciences (SPSS version 23.00) software
relevant factor in the perceived hearing handicap 19.             (SPSS, Inc., Chicago, Il, USA).

Data analysis
Epidemiological features of the participants, such as gen-
                                                                  Results
der, age and 4fPTA, were reported with descriptive statis-        Of the 275 outpatients recruited and examined, 160 were
tics and an independent t-test was used to compare the con-       males (58.2%) and 115 females (41.8%). The mean age
tinuous variables between males and females. In addition,         was 74.5 years (SD = 6.6, range: 65-91). Table I shows
the total score of the HHIE-It as well as the scores of its       the demographic characteristics of the sample. According
subscales were reported with descriptive statistics (Tab. I).     to the WHO’s Grades of hearing impairment 13 based on
Internal and test-retest consistencies of the HHIE-It were        4fPTA, 15 patients (5.5%) had no impairment, 44 (16.0%)
adopted to test reliability. The former was assessed with         had a slight impairment, 87 (31.6%) had mild impairment,
Cronbach’s α 20. According to this model, the more items          88 (32.0%) had moderate impairment, 33 (12.0%) had
in a test are correlated with each other (inter-item correla-     moderately-severe impairment, 6 (2.2%) had severe im-
tions), the greater the value of α. Alpha coefficients ≥ 0.70     pairment and 2 (0.7%) profound impairment (Fig. 1). The
are generally considered indicative of acceptable reliability     mean value of 4fPTA was 39.3 dB HL (range: 10-111.3,
of the scale 12, even if the use of cut-off values is debat-      SD = 16.0). Males were significantly older than females
ed. In addition, the statistical procedure “Cronbach’s α if       (t = -3.06, df = 273, p = 0.002), but the degree of hearing



76
                                                                             Correlations between perceived hearing disability in the elderly and a quality-of-life survey




Table I. Epidemiological features of the sample.
                                                          Total (n = 275)                              Male (n = 115)                              Female (n = 160)
                                                 Mean            SD          min-max          Mean            SD          min-max          Mean            SD       min-max
 Age (years)                                     74.5            6.6           65-91          75.9            6.4          65-91           73.5            6.5        65-90
 4fPTA (dB HL)                                   39.3           16.1          10-101          40.8           16.4         10 - 101         37.2           15.3        10-85
SD: standard deviation; min-max: lowest and highest values; 4fPTA: four frequencies (0.5 KHz, 1 KHz, 2 Khz, 4 KHz) pure tone average threshold in the better ear.



                                                                                             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 signif-
                                                                                             icance = 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 be-
                                                                                             tween the HHIE-It and its subscales (S, E) scores and the
                                                                                             three SF-36 subscales scores (SF, RE and V) (p < 0.001)
Figure 1. Distribution of hearing loss in the sample cases based on 4fPTA                    (Tab. IV). Finally, no ceiling effect was found since no pa-
according to the WHO’s Grades of hearing impairment. None: normal hear-
ing, from -15 to 15 dB HL (15 subjects, 5.5%); Slight hearing loss: from 16 to
                                                                                             tients scored 100 at HHIE-It and only 8 patients (3%) a
25 dB HL (44 subjects, 16.0%); Mild hearing loss: from 26 to 40 dB HL (87                    minimum score (0).
subjects, 31.6%); Moderate hearing loss: from 41 to 55 dB HL (88 subjects,
32.0%); Moderately-severe hearing loss: from 56 to 70 dB HL (33 subjects,
12.0%); Severe hearing loss: from 71 to 90 dB HL (6 subjects, 2.2%); Pro-                    Discussion
found hearing loss: from 91 dB HL (2 subjects, 0.7%).
                                                                                             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.
loss in the better ear did not differ between gender (t = 1.9,
                                                                                             Moreover, Cronbach’s α of the E and S subscales (0.84
df = 255, p = 0.056). Table II shows the total score of the
                                                                                             and 0.93, respectively) closely resemble those of the origi-
HHIE-It and the scores of the two subscales, E and S. No
                                                                                             nal version (0.88 and 0.93). Only the removal of item 21
significant difference was found between males and fe-                                       from the scale slightly improved the overall α coefficient
males with regards to the HHIE-It total score (t = -0.58,                                    of the scale. However, item 21 “Does a hearing problem
df = 268.4, p = 0.557), the S score (t = -0.231, df = 268.9,                                 cause you difficulty when in a restaurant with relatives or
p = 0.817) and E score (t = 0.837, df = 266.2, p = 0.403).                                   friends?” investigates one of the most common complaints
Cronbach’s α coefficient was 0.94 for the total score of the                                 among older hearing-impaired patients, namely speech un-
questionnaire, and 0.84 and 0.93 for the S and E subscales,                                  derstanding in competing background noise 22. We decided
respectively. The procedure ‘Cronbach’s α if item is delet-                                  not to remove it from the scale because it is “necessary and
ed’ pointed out that removal of item 21 improved overall α                                   desirable” for audiologists 5 to pinpoint any specific situa-
coefficient of the scale to 0.957. After its removal, no other                               tion that could be detrimental to social adjustment even if


Table II. Total score of the HHIE-It and scores of its subscales Emotional (E) and Socio-Situational (S). Variables are reported as means, standard deviations (SD)
and lowest and highest values for the entire population and for both genders separately.
                                                      Total (n = 275)                        Male (n = 115)                           Female (n = 160)
                                                 Mean            SD          min-max          Mean            SD          min-max          Mean            SD       min-max
 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)




                                                                                                                                                                               77
F. Di Berardino et al.




Table III. Intraclass correlation coefficients of HHIE-It total score and its subscales (E) and (S) computed between the two surveys, administered at a six weeks
interval time. Intraclass Correlation Coefficient (ICC) estimates and their 95% confidence intervals were calculated based on single measures, absolute-agreement,
2-way mixed-effects model.
                                                  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



Table IV. Correlations between the HHIE-It, its subscales scores and the SF-36 subscales scores.
                                                                                                                                                  SF-36
                                                                                                                              SF                     RE                     V
 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
 HHIE-It: Italian translation of the Hearing Handicap Inventory for the Elderly; E: emotional subscale of the HHIE-It; S: socio-situational subscale of the HHIE-It; SF-36: MOS 36-Item
 Short Form Health Survey; RE: role-emotional subscale of the SF-36; SF: social-functioning subscale of the SF-36; V: vitality subscale of the SF-36. * = p < 0.05; ** = p < 0.005.



not so frequently encountered by the elderly in everyday                                       the degree of hearing loss increases in accordance with the
life. In fact, this study suggested the internal consistency of                                predetermined hypothetical concept adopted in this study.
the HHIA-It to be more than acceptable and all the items                                       Criterion validity was confirmed by significant correlations
of the scale are consistent indicators of hearing handi-                                       between HHIE-It overall score and the scores of its sub-
cap. According to George and Mallery 12, α values equal                                        scales E and S with the corresponding RE and SF of the SF-
or greater than 0.9 are to be considered excellent. On the                                     36. These results confirm that hearing handicap is related
other hand, a very high α value could indicate redundancy                                      to both psychological distress and poor social adjustment.
between items in the scale, but exploring the possibility of                                   Difficulties in taking part in conversation with relatives and
a shorter version was beyond the purpose of this validation                                    friends and subsequent frustration facilitate loneliness and
study. Many factors can affect the score of a questionnaire                                    depression. In addition, this study disclosed a negative cor-
at different points in time: for instance, patients’ respons-                                  relation between the severity of subjective hearing handi-
es might be influenced by pathological changes, different                                      cap and vitality, as assessed by the V subscale of the SF-36.
moods, or external conditions. Furthermore, the subject’s                                      Indeed, lack of energy, exhaustion and chronic feelings of
memory of the scale items might contribute to an exceed-                                       fatigue could be associated with hearing loss through the
ingly strong correlation between the two surveys. As a rule                                    increased listening effort 24. Furthermore, dissipated vigour
of thumb, an interval time of at least six weeks between                                       arising from daily life engagement of cognitive resources
the two administrations adopted in this study is suggested                                     for speech perception may be one of the most relevant
to counteract this latest factor 23. Thus, both a significant                                  contributors to hearing loss related disability 25. Another
Pearson’s correlation coefficient and ICC between the                                          important factor of this validation study is the exclusion
scores of the questionnaire and its subscales suggest that                                     of ceiling and floor effects of the HHIE-It questionnaire,
the HHIE-It resists all the other risks. Compared to other                                     which indicate the percentages of respondents scoring the
adaptations of audiological disease-specific questionnaires                                    highest (ceiling) or lowest (floor) extremes of the scale. If
into Italian language 23, construct validity of HHIE-It was                                    a large proportion of patients report the highest or lowest
shown to be more straightforward because a robust and di-                                      possible score for a questionnaire, then the tool is not ad-
rect correlation between an objective measure of hearing                                       equate to distinguish between respondents at the extreme
impairment (4fPTA) and perceived hearing handicap was                                          ends of the scale 21. Since the floor/ceiling effect was re-
documented. In other words, HHIE-It scores improve as                                          ally scarce in this sample of hearing-impaired older adults,



78
                                                       Correlations between perceived hearing disability in the elderly and a quality-of-life survey




this risk was considered negligible. Some limitations of             References
this study are pertinent. A limitation of this study was the         1
                                                                          Department of Economic and Social Affairs, Population Dynamics,
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                                                                          31, 2022).
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                                                                     3
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ing impairment. In view of this, there is a concern about the             org/10.1001/archinternmed.2011.506
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to their hospitalised peers.                                         5
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Conclusions                                                               org/10.1097/00003446-198205000-00006
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HHIE is a valid and reliable instrument to investigate the                299. https://doi.org/10.1097/00003446-198610000-00002
amount of perceived handicap related to hearing impair-
                                                                     7
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                                                                          specific self-report measures and their associations with psychosocial
ment in the community-dwelling older adults. The HHIE-It                  and demographic variables. Audiol Med 2007;5:188-199. https://doi.
demonstrated favourable psychometric properties overlap-                  org/10.1080/16513860701560214
ping those of the original version and its adoption is justi-        8
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                                                                          tory for the elderly questionnaire among elderly subjects in Saga-
fied for both clinical and research purposes in Italy.
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Conflict of interest statement                                       9
                                                                          De Paiva SMM, Simões J, Paiva A, et al. Validity and reliability of the
The authors have no personal, financial, and institutional                hearing handicap inventory for elderly: version adapted for use on the
                                                                          portuguese population. J Am Acad Audiol 2016;27:677-682. https://
interest in any of the materials and devices described in                 doi.org/10.3766/jaaa.15146
this article.                                                        10
                                                                          Laohasiriwong S, Kasemsiri P, Thanavirathananich P, et al. Validity
                                                                          and test-retest reliability of Hearing Handicap Inventory for the Elder-
Funding                                                                   ly Thai Version (HHIE-Thai). Ann Otolaryngol Rhinol 2018;5:1204.
                                                                          https://doi.org/10.47739/2379-948X/1204
Internal departmental funding was used to support this               11
                                                                          Ismail N, Shalaby A, Behairy R, et al. The developed Arabic version
study without commercial sponsorship.                                     of the Hearing Handicap Inventory for the Elderly. Egypt J Otolaryn-
                                                                          gol 2020;36. https://doi.org/10.1186/s43163-020-00004-6
Author contributions                                                 12
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script; BA: investigation, acquisition of data; EA: statistical           ness and hearing impairment. Report of the Informal Working Group
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conception of the study; DM: conception and design of the                 ning, Geneva, Switzerland; 18-21 June, 1991. World Health Organi-
                                                                          sation 1991 https://apps.who.int/iris/handle/10655/58839 (accessed
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proval. All Authors contributed to the article and approved          14
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of the last revision of WMA Declaration of Helsinki for                   doi.org/10.1016/s0895-4356(98)00094-8
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                                                                     Correlations between perceived hearing disability in the elderly and a quality-of-life survey




Appendix I.

The Italian translation of the Hearing Handicap Inventory for Elderly (HHIE-It), aimed at subjects aged over 65. Items
number 2, 4, 5, 7, 9, 12, 14, 17, 18, 20, 22, 24, 25 correspond to the emotional subscale and items number 1, 3, 6, 8, 10, 11,
13, 15, 16, 19, 21, 23 rank the magnitude of socio-situational limitation.



 The Hearing Handicap Inventory for Elderly – Italian Version (HHIE-IT)                                           4                   2                    0
 1           Un problema di udito La obbliga a usare il telefono meno di quello che Le piacerebbe fare?          SI            QUALCHE VOLTA              NO
 2           Un problema di udito Le crea imbarazzo quando conosce nuove persone?                                SI            QUALCHE VOLTA              NO
 3           Un problema di udito La costringe a evitare la compagnia di altre persone?                          SI            QUALCHE VOLTA              NO
 4           Un problema di udito La rende irritabile?                                                           SI            QUALCHE VOLTA              NO
 5           Un problema di udito La fa sentire frustrato mentre parla con i familiari?                          SI            QUALCHE VOLTA              NO
 6           Un problema di udito Le crea difficoltà a partecipare a una festa?                                  SI            QUALCHE VOLTA              NO
 7           Un problema di udito La fa sentire stupido o taciturno?                                             SI            QUALCHE VOLTA              NO
 8           Un problema di udito Le crea difficoltà quando qualcuno parla sussurrando?                          SI            QUALCHE VOLTA              NO
 9           Si sente handicappato a causa del Suo problema di udito?                                            SI            QUALCHE VOLTA              NO
 10          Un problema di udito Le causa difficoltà quando fa visita agli amici, parenti o vicini di           SI            QUALCHE VOLTA              NO
             casa?
 11          Un problema di udito Le crea problemi al cinema e/o a teatro?                                       SI            QUALCHE VOLTA              NO
 12          Un problema di udito La rende nervoso?                                                              SI            QUALCHE VOLTA              NO
 13          Un problema di udito La costringe a fare meno visite agli amici, ai parenti, ai vicini rispetto     SI            QUALCHE VOLTA              NO
             a quanto vorrebbe?
 14          Un problema di udito causa delle discussioni in famiglia?                                           SI            QUALCHE VOLTA              NO
 15          Un problema di udito Le causa problemi quando ascolta la radio o la televisione?                    SI            QUALCHE VOLTA              NO
 16          Un problema di udito La costringe a visitare meno i negozi di quanto vorrebbe?                      SI            QUALCHE VOLTA              NO
 17          Un qualsiasi problema o difficoltà nell’udito La sconvolge completamente?                            SI           QUALCHE VOLTA              NO
 18          Un problema di udito La costringe a restare solo/a?                                                  SI           QUALCHE VOLTA              NO
 19          Un problema di udito La obbliga a parlare meno con i familiari rispetto a quanto vorrebbe?           SI           QUALCHE VOLTA              NO
 20          Le sembra che qualsiasi difficoltà con il Suo udito limiti o ostacoli la Sua vita personale e        SI           QUALCHE VOLTA              NO
             sociale?
 21          Un problema di udito Le crea difficoltà quando si trova in un ristorante con amici o                 SI           QUALCHE VOLTA              NO
             parenti?
 22          Un problema di udito La fa sentire depresso?                                                         SI           QUALCHE VOLTA              NO
 23          Un problema di udito La obbliga ad ascoltare meno radio e TV di quello che vorrebbe?                 SI           QUALCHE VOLTA              NO
 24          Un problema di udito La fa sentire a disagio quando parla con gli amici?                             SI           QUALCHE VOLTA              NO
 25          Un problema di udito La fa sentire escluso/a quando si trova in un gruppo di persone?                SI           QUALCHE VOLTA              NO




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