Objectives: The objectives are to develop the Hearing Handicap Inventory for  Elderly Thai version (HHIE-Thai), to validate its content and construct validity, and to   assess the test-retest reliability.
Design: The HHIE was translated into Thai language and was tested for content  and construct validity. Ten subjects were tested by self-administration and interview.  The test-retest reliability was conducted in 50 hearing impaired elderly adults tested  one month apart by interview without any hearing rehabilitation. 
Results: The Pearson’s product-moment correlation of the total score was r = 0.90  (95% CI 0.63 - 0.98, p< 0.001), the social items r= 0.90 (95% CI 0.73 - 0.98, p<  0.001) and the emotional items r= 0.93 (95% CI 0.63 - 0.98, p< 0.001). Fifty subjects  mean age 74.12 ± 7.66 years, 31 males (62%) 19 females (38%).Most subjects  had primary school education and lower income. The test-retest reliability Cronbach’s  alpha of 0.82 for the total score and intra-class correlation (ICC) was 0.63. Each of the  25 items had high correlation alpha ranging from 0.81 to 0.83. 
Conclusions: The Hearing Handicap Inventory for Elderly Thai version (HHIE-Thai)  has a good internal consistency, good construct validity and test-retest reliability. It can  be used either by self-administration in literate subjects or by face to face interview  in less literate subjects.

• Hearing loss

• Disability evaluation

• Aural rehabilitation

• Hearing handicap inventory in elderly

• Quality of life

Laohasiriwong S, Kasemsiri P, Thanavirathananich P, Yimtae K (2018) Validity and Test-Retest Reliability of Hearing Handicap Inventory for the Elderly Thai Version (HHIE-Thai). Ann Otolaryngol Rhinol 5(1): 1204.

HHIE-Thai: Hearing Handicap Inventory for Elderly Thai version; HUI®: Health Utilities Index; EQ5D: European Quality of Life Questionnaire in 5 Domains; SF-36: Medical Outcome Study 36-item Short Form

Over 5% of the world’s population has disabling hearing loss (328 million adults and 32 million children). Approximately one-third of people over 65 years of age are affected by disabling hearing loss. The prevalence in this age group is greatest in South Asia, Asia Pacific and sub-Saharan Africa. The majority of people with disabling hearing loss live in low- and middle-income countries. In which the prevalence of hearing loss decreases exponentially as income increases [1,2] (Figure 1).

Figure 1: Educational background of the test-retest reliability of the Hearing Handicap Inventory for Elderly Thai version (HHIE-Thai) subjects.

In Thailand hearing aids may be reimbursed for individuals with a hearing threshold more than 40 dB in the better hearing ear. However with the disproportion of audiologists and otolaryngologists per population in Thailand, hearing evaluation and aural rehabilitation is still lacking. To be able to provide assistive devices for those whom would most benefit based on limited budget and resources is a challenging task. Furthermore assessing the hearing threshold alone does not reflect improvement of the person’s function or quality of life. There’s a need for a tool to evaluate this in hearing impaired individuals. There are many quality of life assessment tools such as the Health Utilities Index (HUI®) and the European Quality of Life Questionnaire in 5 Domains (EQ5D). The HUI Mark 3 (HUI3) instrument is comprised of 8 attributes – vision, hearing, speech, ambulation, dexterity, emotion, cognition and pain – each with 5 or 6 levels of ability/disability [3] EQ5D assesses five dimensions i.e. mobility, self-care, usual activities, pain/discomfort and anxiety/depression. However, these questionnaires give an assessment of general health, evaluating hearing is only one part of the many aspects in global quality of life. An assessment tool that can evaluate hearing, reflecting in the context of quality of life, socialization and need of hearing assistive devices is warranted

The Hearing Handicap Inventory for Elderly (HHIE) is a validated self-assessment tool with 25 items, 13 items assessing the emotional consequences and 12 items assessing social/situational consequences of hearing impairment. It was developed by assessing elderly people living in the community [4], showing to correlate well with audiometric evaluation [5]. It has also been used to evaluate subjects who used hearing aids and showed that the HHIE scores improved after continuous use of hearing aids [6,7].

Our goal is to validate a questionnaire that could be used as a screening tool to assess the impact of hearing loss towards quality of life [8,9]. The validated tool can be further developed to correlate with hearing levels and used as a tool for assessment in the community by primary health care providers before referral to specialized personnel for hearing rehabilitation. The objectives of this study are to develop the Hearing Handicap Inventory for Elderly Thai version (HHIE-Thai), to validate its content and construct validity, and assess the test-retest reliability.

Following Khon Kaen University ethics committee approval, the HHIE was translated into Thai language by a native Thai speaker fluent in English. The HHIE-Thai was translated back into English by two independent otolaryngologists who are English fluent and naïve to the original HHIE. The back translated questionnaires were compared and any dissimilar words or phrases in the Thai version were considered and selected by one of the authors (K.Y.), a linguist expert was consulted to correct any grammatical errors. The HHIE-Thai was tested for cognitive debrief by 10 Thai volunteers who were recruited from the general otolaryngology clinic, Srinagarind Hospital, Khon Kaen, Thailand. The inclusion criteria were; 1) age more than 60 years old 2) had an indication for audiometry testing or hearing aid evaluation 3) able to read the HHIE-Thai by themselves 4) willing to participate in the study by self-administration (paper-pencil) then interviewed by a trained research assistant (face to face). Some Thai words in the HHIE-Thai that were confusing for the subjects were changed to make the question more comprehensible, while still maintaining the same meaning. A second back translation into English was conducted. A second cognitive debrief was done in 30 subjects both by self-administration and interview to finalize the final version of HHIE-Thai.Construct validity of the HHIE-Thai was tested by four independent otolaryngologists and compared to the original HHIE (Figure 2).

Figure 2: Socioeconomic status of the test-retest reliability of the Hearing Handicap Inventory for Elderly Thai version (HHIE-Thai) subjects. * 35 Thai Baht (THB)= 1 US dollar (USD)

To examine the test-retest reliability, fifty hearing impaired patients who had different degrees of hearing loss ranging from mild to moderately severe hearing loss were recruited. They were hearing aid candidates for another separate trial. These subjects came from different communities covering 3 sub districts of Phu Wieng District. A rural area in the northeast of Thailand which represents the rural living of the majority of Thailand’s population. All the participants provided informed consent. The subjects administrated the HHIE-Thai via an interview and repeated one month later by the same trained research assistant. Subjects were elderly and most of them had difficulties to read due to aging. They had different degrees of literacy. Thus interview (face to face) was chosen to facilitate data collection.The interviewer was trained to ask the questions in the same format with a set of descriptive words to help explain if the subject does not understand the keyword to maintain the content validity. None of the subjects had chronic illnesses or other diseases that may cause hearing loss. The study registered clinical trial no. Was NCT 01902914.

Statistical analysis

The demographic data was analyzed by descriptive methods. The internal consistency was examined by Pearson’s product moment correlation coefficient and Cronbach’s alpha. Intra-class correlation efficiency was used for test-retest reliability.When conducting the interview, the subject must be able to understand the item (≥90%) to be considered that they comprehend the item. Paired student T-test was used to compare the scores in the second cognitive debrief between self-administration and interview method. All statistics were considered significant for a p value less than 0.05. Statistical analyses were performed by using STATA software version 10 (Stata Corp, Texas, USA).

Data was collected from October 1, 2012 until April 30, 2013. The construct validity of the HHIE-Thai items 1, 3, 11, 13, 16, 19 and 23 were determined as social/situational assessments similar to the English HHIE. Items 2, 4, 5, 7, 9, 12, 17, 20, 22, 24 and 25 were determined as similarly emotional assessments. Items 6, 8,10, and 21 were social but seen as emotional evaluation in the Thai version. Item 14 and 18 were emotional assessments but seen as able to be either emotional or social aspect. Ten subjects were enrolled for the validity and cognitive debrief process.

The Pearson’s product-moment correlation of the total score was r = 0.90 (95% CI 0.63 - 0.98, p< 0.001), the social items r= 0.90 (95% CI 0.73 - 0.98, p< 0.001) and the emotional items r= 0.93 (95% CI 0.63 - 0.98 p< 0.001). Each of the 25 items had high correlation alpha ranging from 0.81 to 0.83. Cronbach’s alpha of the total score was 0.82. In the second cognitive debrief 30 subjects who did the HHIE-Thai by self-questionnaire compared with face to face interview, the score difference was not statistically significant. The paired difference T-test was 0.40 (p=0.693).

Fifty subjects who had good understanding of Thai language, and lived in Phu Wieng District, Khon Kaen, Thailand were enrolled. The mean age was 74.12 ± 7.66 years, 31 males (62%) 19 females (38%).Most subjects had primary school education(84.3%), 7.2% had less than primary school education and the rest had higher than secondary school education. Most of the subjects (66.3%) had income lower than 5,000 baht per month (150 USD). One of the 50 subjects withdrew and did not complete the second test, so this subject was excluded. The testretest reliability intra-class correlation (ICC) was 0.63.

Hearing loss in the elderly can affect quality of life and wellbeing [8]. Hearing rehabilitation can provide significant improvement of the psychosocial and cognitive condition [9– 11]. The Hearing Handicap Inventory for Elderly has been used worldwide [12] and translated and validated in many countries [13,14]. The Hearing Handicap Inventory for Elderly Thai version (HHIE-Thai) has a high correlation both on the emotional, social/ situational subscales and total scores. When the construct validity was tested, most of the items were consistent with the same evaluation aspect. Items 6, 8 and 21 were social situations asking about hearing difficulties when attending a party (item 6), when listening to someone speak in a whisper (item 8) and when in a restaurant with relatives or friends (item 21), in the Thai version they were grouped as an emotional evaluation possibly due to perception that these impairments will cause emotional anxiety to the individual in those situations and not viewed as a purely socialization problem. Items 14 (Does a hearing problem cause you to have arguments with family members?) and item 18 (Does a hearing problem cause you to want to be by yourself?) were seen as could be either emotional or social evaluation, possibly due to viewing if these social interaction problem occurred it would definitely impact the individual’s emotion. The difference is not due to language difference but possibly due to the different cultural context.

The Hearing Handicap Inventory for Elderly Thai version (HHIE-Thai) has a good internal consistency, good construct validity and test-retest reliability. It can be used either by selfadministration in literate subjects or by face to face interview in less literate subjects.

We would like to thank the research assistants who were essential in conducting this study: Kaewjai Thepsuthammarat, PhD (for data analysis), Prakongluck Jaglang and her team, Nisa Gaesorn, Anthika Daengcote, and Namthip Saeng prasert.

This research was funded by The Health System Research Institution, Thailand and partially supported from the Faculty of Medicine, Khon Kaen University, Thailand.

This article was presented as an oral presentation at the 17th International Congress in Audiological Medicine – IAPA 2014, Chonburi, Thailand, November 5, 2014.

1. Deafness and hearing loss.

2. Mortality and Burden of Diseases and Prevention of Blindness and Deafness. 2012.

3. Horsman J, Furlong W, Feeny D, Torrance G. The Health Utilities Index (HUI®): concepts, measurement properties and applications. Health Qual Life Outcomes. 2003; 1: 54.

4. Ventry IM, Weinstein BE. The hearing handicap inventory for the elderly: a new tool. Ear Hear. 1982 ; 3: 128–134.

5. Weinstein BE, Ventry IM. Audiometric correlates of the Hearing Handicap Inventory for the elderly. J Speech Hear Disord. 1983; 48: 379–384.

6. Newman CW, Weinstein BE. The Hearing Handicap Inventory for the Elderly as a measure of hearing aid benefit. Ear Hear. 1988; 9: 81–85.

7. Mizutari K, Michikawa T, Saito H, Okamoto Y, Enomoto C, Takebayashi T, et al. Age-Related Hearing Loss and the Factors Determining Continued Usage of Hearing Aids among Elderly Community-Dwelling Residents. PLoS ONE [Internet]. 2013; 23: 8.

8. Dalton DS, Cruickshanks KJ, Klein BEK, Klein R, Wiley TL, Nondahl DM. The impact of hearing loss on quality of life in older adults. Gerontologist. 2003; 43: 661–668.

9. Carniel CZ, Sousa JCF de, Silva CD da, Fortunato-Queiroz CA de U, Hyppolito MÂ, Santos PLD. Implications of using the Hearing Aids on quality of life of elderly. CoDAS. 2017; 29: e20160241.

10. Lotfi Y, Mehrkian S, Moossavi A, Faghih-Zadeh S. Quality of life improvement in hearing-impaired elderly people after wearing a hearing aid. Arch Iran Med. 2009; 12: 365–370.

11. Acar B, Yurekli MF, Babademez MA, Karabulut H, Karasen RM. Effects of hearing aids on cognitive functions and depressive signs in elderly people. Arch Gerontol Geriatr. 2011; 52: 250–252.

12. Ferguson MA, Kitterick PT, Chong LY, Edmondson-Jones M, Barker F, Hoare DJ. Hearing aids for mild to moderate hearing loss in adults. Cochrane Database Syst Rev. 2017; 9: CD012023.

13. Sogebi OA, Mabifah TO. Validation of hearing handicap inventory for the elderly questionnaire among elderly subjects in Sagamu, Nigeria. Niger Postgrad Med J. 2015; 22: 228–232.

14. De Paiva SMM, Simões J, Paiva A, Newman C, Castro E Sousa F, Bébéar J-P. Validity and Reliability of the Hearing Handicap Inventory for Elderly: Version Adapted for Use on the Portuguese Population. J Am Acad Audiol. 2016; 27: 677–682.

15. Weinstein BE, Spitzer JB, Ventry IM. Test-retest reliability of the Hearing Handicap Inventory for the Elderly. Ear Hear. 1986; 7: 295– 299