The Psychometric Properties Persian version of the Hearing Handicap Inventory Screening Version (HHIE-S) Among Older Adults

Background: there is a great need for a valid hearing loss measurement tool in the Persian language to help identify hearing handicap and potential communicational dif ﬁ culties among Persian speaking older adults. Objectives: The present study was aimed to validate and adapt the original English version of Hearing Handicap Inventory for the Elderly (HHIE) into Persian language. Methods:A cross-sectional study was designed and data was collected from August to November 2019 in Tabriz, Iran among the older adults aged 60 years and above whose hearing loss had been conrmed by audiometry. Self-reporting and face-to-face interviews were the data collection methods in this study. The statistical analysis was performed using SPSS 26.0 (SPSS and STATA 14). Results: An exploratory factor analysis of data resulted in two factors, which included 9 of the 10 items and accounted for 87.00% of the variance. Cronbach’s alpha coecient (0.85) and the test–retest reliability score (0.73) indicated good internal consistency. Conclusion : The results showed that HHIE-S is a valid and reliable tool for assessing hearing handicap among Persian speaking and Iranian older adults.


Introduction
Ageing is associated with various underlying physiological changes and increased risk of experiencing more than one chronic condition [1]. One of the most common chronic diseases/ conditions of old age is "Hearing loss" [2]. Hearing loss is the third most common chronic condition affecting older adults as well as their daily communications [3]. However, these people are usually are not insight about their hearing loss condition and may be under-reported [4].
Hearing loss has numerous adverse impact on the psychological and social well-being of older adults [2] because it affects nearly on all aspects of daily life. Hearing loss interferes with solitary activities, such as listening to the television or radio. Additionally, di culty in using the telephone may in uence on older adults' communication who are living alone [5]. Moreover, di culty in recognition of the spoken words, needing to a repetition of words by others, and uncertainty about having understood correctly, often lead to withdrawal from social activities, such as diminished attendance at a social gathering such as theatres, cinemas, churches, lectures, etc. This di culty in recognition of words leads to declined intellectual and social interaction [6]. Therefore, hearing loss can lead to social isolation, depression, anxiety, poor quality of life, and even cognitive performance decline in the old ages [7].
To manage and prevent these negative consequences of hearing loss, clinicians should attempt to early diagnose of hearing impairment as an integral part of the comprehensive geriatric assessment. Currently, the gold-standard method for early clinical detection of hearing loss is audiogram, but less access to audiometry centers and costs of audiogram may restrict referring to the health centers [8]. Lutman (1991) and Ventry and Weinstein (1983) proposed that the hearing di culties among the older adults can be measured by a self-report manner rather than audiometric data [9,10]. Self-report measures help identify hearing handicap and potential communicational di culties and also have an essential place role in the e ciency of hearing impairment screening programs for older adults [11].
The self-administered hearing loss tools are widely used as a quick and inexpensive method to screen hearing loss in clinical settings [8]. Several questionnaires for assessing of hearing disability have been developed and used in the English-speaking population such as the Hearing Disability and Handicap Scale (HDHS) [12], the Gothenburg Pro le (GP) [13], the Hearing Handicap Questionnaire (HHQ) [14], Complete Intelligibility Spatiality Quality (CISQ) [15], the Speech Spatial and Qualities of Hearing Scale (SSQ) [16], and the Hearing Handicap Inventory for the Elderly (HHIE) [17]. But among these tools, HHIE was more widely used in hearing loss assessment among older adults [18].
In 1982, Ventry and Weinstein has developed the 25-item HHIE to assess psychosocial handicap of hearing impairment in the elderly ages [17]. It was incorporated for use in community-based studies among older adults, especially in inaccessible rural areas of developed countries [19,20]. A shorter widely used 10-item version of the HHIE-S was developed next in 1986 as a screening tool for handicapping hearing loss [21]. This screening instrument is widely used and its reliability and validity have been well established in numerous studies [21,22]. This tool has been found to have high internal consistency reliability and high test-retest consistency for different languages [21,23]. Due to its reliability, validity, and brevity, the HHIE-S has also been found to be effective tool in measuring the performance of different types of hearing aid tools [24][25][26]. In addition, it is available in many languages, including Spanish [19], Chinese [27], Iindia [20], Portuguese [28], Swedish [29]. Since there is a great need for a valid hearing loss measurement tool in the Persian language, the present study was aimed to validate and adapt the original English version of HHIE-S into Persian language and consequently using HHIE-S among older adults.

Participant and procedures
The study applied a cross-sectional design which was conducted from August to November 2019 in Tabriz, Iran. Through convenience sampling, a total of 210 older adults aged 60 + years were enrolled in the study. This sample size was arrived based on the recommendation of having at least 5 to 10 participants per the scale's items [30]. The inclusion criteria were people 60 years of age or older; who were able to understand and be able to speak the Persian language; and their hearing loss had been con rmed by audiometry. The exclusion criteria included inability to give informed consent and any cognitive impairment (as assessed by Abbreviated Mental Test). Self-reporting and face-to-face interviews were the data collection methods in this study. This research was approved by the Ethics Committee of the Tabriz University of Medical Sciences (IR.TBZMED.REC.1397.327). Informed consent in writing was taken by all the study participants. All the participants were ensured the con dentiality of their responses, identity, and the right to withdraw from the study at any stage.

Translation procedure
First, HHIE-S scale was translated from English to the Persian language according to the guidelines stated by the experts [31]. Next, back-translation to the English language was performed by another bilingual translator. An advisory panel of academic and clinical experts, including an occupational therapist, a clinical psychologist, audiometers and a sociologist, collaborated to review the Persian version. A few minor amendments were made to some of the wordings to enhance readability. The consensus of all authors con rmed the nal translation.

Measures
The HHIE-S comprises ten (10) items that were selected from the 25-item version of the HHIE (10). The HHIE includes two domains: (1) Emotional, (2) Social. Of the ten items, ve items explore the emotional consequences (HHIE-E) while the remaining ve items explore the social or situational effects (HHIE-S). There are three response options for each item, namely yes (score = 4), sometimes (score = 2), or no (score = 0). These scores are summed up, and higher scores indicate greater perceived activity limitation and participation restriction. The scoring is divided into three broad categories: 1) Scores of 0 to 10 represent little, or no activity limitations or participation restrictions; 2) scores of 12 to 24 indicate mildmoderate limitations and restrictions and 3) scores of 26 to 40 indicate signi cant limitations and restrictions [21]. When implementing this tool to measure the effect of hearing aid rehabilitation, it has been recommended that the pre-and post-rehabilitation scores should vary by at least 10 points for the hearing aid intervention efforts to be considered effective [32].

Statistical analysis
The statistical analysis was performed using SPSS 26.0 (SPSS Inc., Chicago, IL, USA) and STATA 14 (Stata Corp, College Station, TX). The normality assumption of the data was examined by using skewness and kurtosis measures. The normality of distribution was checked by descriptive measures such as coe cients of skewness and kurtosis, mean and standard deviation [33].Several statistical approaches were also used to assess the psychometric properties of the HHIE-S and were deployed in the following order.

Construct validity
The Exploratory Factor Analysis (EFA) and Con rmatory Factor Analysis (CFA) were performed to examine the construct validity of the HHIE-S. The EFA was conducted using Principal Axis Factoring (PCF) by varimax rotation. The Kaiser-Meyer-Olkin (KMO) test and Bartlett's test of sphericity were used to check the appropriateness of the study sample and the factor analysis model. The number of factors was con rmed based on eigenvalues and scree plot. Items with absolute loading values of 0.3 or greater were regarded as appropriate [34]. Bartlett's test of sphericity and KMO measure of sampling adequacy and total variance explained were used to assess model su ciency [35]. The KMO values higher than 0.7, signi cant values of Bartlett's test of sphericity (< 0.05), and factor loadings ≥ 0.3 were considered for interpretation [36]. Additionally, Con rmatory Factor Analysis (CFA) was conducted to assess how well the EFA extracted model ts the observed data. The weighted least squares estimation method was used with a weighted matrix of asymptomatic covariances. Fit indices and reasonable values of these indices were considered as χ2 / df < 5, Root Mean Square Error of Approximation (RMSEA) < 0.08, Tucker Lewis index (TLI) ≥ 0.90, Comparative Fit Index (CFI) > 0.90, and also Standardized Root Mean Square Residual (SRMSR) < 0.08 [37].

Reliability
Reliability of the tool was calculated by internal consistency and test-retest reliability. The internal consistency was measured by computing Cronbach's alpha coe cient. Moreover, "alpha if item deleted" for each item was calculated. To inspect test-retest reliability, a subgroup of the same medical students completed the questionnaire twice, separated by a 2-week interval, and Interclass Correlation Coe cient (ICC) was calculated. The satisfactory value of Cronbach's alpha and ICC was considered (≥ 0.70) [38].

Sample characteristics
The older adults who participated in the study consisted of 112 (53.3%) men and 98 (46.7%) women. A majority of participants were 60-69 years old (54.3%), secondary education (34.3%), living with a spouse (37.1%). Other characteristics are shown in Table 1. Construct validity EFA was performed on ten items through the principal axis factoring method. The KMO value was calculated as 0.87. Bartlett's test achieved a value of 856.83 at a signi cant level of less than 0.001, justifying the implementation of factor analysis on the sample based on the correlation matrix. The number of factors was con rmed using a scree plot of eigenvalues. The results demonstrated that the highest percentage of the total variance (57.50%) was explained by two factors which are summarized in Table 2.  Table 2 CFA was conducted to test the tness of the model obtained from EFA. As shown in Fig. 1, all goodnessof-t indices (RMSEA = 0.07, TLI = 0.94, CFI = 0.96, and SRMSR = 0.04.) were satisfactory (Table 3).  Insert about Table 4 Discussion The study was aimed to examine psychometric properties of the HHIE-S among Iranian older adults. This study is the rst to describe and examine the psychometric characteristics of the HHIE-S in Persian language and among the population of older adults in Iran. In translation and cultural adaptation of HHIE-S, we were not faced with serious problems. As such, it was not necessary to make major changes in the original version of HHIE-S, and its validity and reliability indices were satisfactory.
Our study indicated that although the HHIE-S was developed and known as a self-administered questionnaire, illiterate or people with a low level of literacy, were not able to complete the questionnaire by themselves. Hence, for these participants, we used a face to face interview to complete the questionnaire.
The study ndings demonstrated that the HHIE-S adapted to the Persian language maintained its original reliability and validity. The test-retest reliability and Cronbach's α were acceptable for total scale, and subscales re ected su cient internal consistency of the HHIE-S, consistent with the ndings of other psychometric studies of the HHIE-S on other socio-cultural contexts [31,39].
The current results of exploratory factor analysis (EFA) suggested a two-factor structure as an optimized structure that this nding is consistent with other studies [26,40]. Besides, the results obtained from the con rmatory factor analysis (CFA) indicated that the two-factor model ts very well with the data. Unlike the original scale of HHIE-S, item 6 did not load, this may be due to the cultural differences between the two study locations or contextual characteristics that existed within the studied populations.
The study had two limitations, rst, HHIE-S is a self-administered questionnaire; therefore, results may be affected by response bias, and second, our study participants were not randomly selected because of limitation to reach participants.

Conclusion
The results showed that the Hearing Handicap Inventory for the Elderly-Screening (HHIE-S) is a valid and reliable tool for assessing hearing handicap among Persian speaking and Iranian older adults.

Declarations
Ethics approval and consent to participate Ethical approval for the study was provided by Ethics Committee in Tabriz University of Medical Sciences (Ethics Code: IR.TBZMED.REC.1397.327). The written informed consent form was obtained from all the participants before the study.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interest
The authors claim no con ict of interests with other people or organizations Funding This article is part of a Master of Science thesis in health education and promotion, which was supported and approved by Tabriz University of Medical Sciences, Tabriz, Iran. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Author contributions LB, FA, HA designed the study. SS collected survey data. HH, MAJ, HA analyzed and present statistical results. LB, ,HH,VKC, HA were major contributors in writing the manuscript. HA and VKC edited the manuscript. All authors read and approved the nal manuscript. Con rmatory Factor Analysis of the Two-factor Model of the HHIE-s

Supplementary Files
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