TRANSLATION AND ADAPTATION OF HEARING HANDICAP

INVENTORY FOR ADULT (HHIA) INTO MALAY LANGUAGE:

A PILOT STUDY

TENGKU ZULAILA HASMA TENGKU ZAM ZAM, B. AUD (HONS)

DEPARTMENT OF AUDIOLOGY AND SPEECH-LANGUAGE PATHOLOGY,
KULLIYYAH OF ALLIED HEALTH SCIENCES, INTERNATIONAL ISLAMIC
UNIVERSITY MALAYSIA, JLN SULTAN AHMAD SHAH, BANDAR INDERA
MAHKOTA 25200 KUANTAN, PAHANG, MALAYSIA
[email protected]

AHMAD AIDIL ARAFAT DZULKARNAIN, PhD (CORRESPONDING

AUTHOR)
DEPARTMENT OF AUDIOLOGY AND SPEECH-LANGUAGE PATHOLOGY,
KULLIYYAH OF ALLIED HEALTH SCIENCES, INTERNATIONAL ISLAMIC
UNIVERSITY MALAYSIA, JLN SULTAN AHMAD SHAH, BANDAR INDERA
MAHKOTA 25200 KUANTAN, PAHANG, MALAYSIA
[email protected]

SARAH RAHMAT, PhD

DEPARTMENT OF AUDIOLOGY AND SPEECH-LANGUAGE PATHOLOGY,
KULLIYYAH OF ALLIED HEALTH SCIENCES, INTERNATIONAL ISLAMIC
UNIVERSITY MALAYSIA, JLN SULTAN AHMAD SHAH, BANDAR INDERA
MAHKOTA 25200 KUANTAN, PAHANG, MALAYSIA
[email protected]

MASNIRA JUSOH, MSc

DEPARTMENT OF AUDIOLOGY AND SPEECH-LANGUAGE PATHOLOGY,
KULLIYYAH OF ALLIED HEALTH SCIENCES, INTERNATIONAL ISLAMIC
UNIVERSITY MALAYSIA, JLN SULTAN AHMAD SHAH, BANDAR INDERA
MAHKOTA 25200 KUANTAN, PAHANG, MALAYSIA
[email protected]

ABSTRACT

Introduction: Patient’s self-perceived handicap inventory is an important tool for

modern’s healthcare management including hearing loss. The HHIA is a self-
reporting outcome measurement invented to identify hearing-impaired patients’
complaints for appropriate client-centred rehabilitation program. HHIA has been
 PILOT STUDY FOR MALAY HHIA VALIDATION ………..

reported among one of the valid self-perceived hearing handicap measures, and
could even address issues for patients with mild and unilateral hearing loss. This
study aims to translate HHIA into Malay language (HHIA-M) and to adapt the
questionnaire culturally for clinical use among Malaysian population.

Methods: Ten participants involved in this preliminary study. The questionnaire

was initially translated using forward-backward techniques by four-panelists (2
panels for each level). The translated questionnaire was then reconciled and
harmonized for cultural and content validations by the authors and two expert
panels. Next, the harmonized version of the questionnaire was piloted among 10
hearing-impaired patients and 10 normal hearing participants for face and
discriminant validation. All participants were recruited from IIUM Hearing and
Speech Clinic.

Results: The finding shows that the HHIA-M was easy to understand and took a
short time to complete. Statistical analysis identified significant mean differences
in HHIA scores between normal and hearing-impaired participants.

Conclusions: This preliminary finding concluded that the HHIA-M has the
potential to be an effective tool to evaluate the hearing handicaps among hearing-
impaired patients in Malaysia and further study to investigate its psychometric
property is warranted.

KEYWORDS: Hearing-impaired; HHIA; HHIA-M; Translation; Pilot study

INTRODUCTION

Self-reported outcome measurement that quantify patient’s disability and

functioning affected by hearing impairment play an important role in aural
rehabilitation. This is in parallel with the International Classification of
Functioning, Disability and Health (ICF) requirement, where specific areas of
difficulty experienced by the patients need to be identified, and clinicians may use
this information for direct intervention to the relevant areas of need (Lynn, 1986).
Traditionally, objective outcome measures such as real ear measurement and
speech recognition test are widely used by audiologist in Malaysia (Aiello et al.,
2011). While the objective tests have several advantages, these tests only measure
the functional improvement in sounds perception resulted from amplification. For
that reason, subjective test such as the self-outcome measurement is also used as it
provides more information on patient’s quality of life resulting from the hearing
impairment (Davis & Hardick, 1981; Cox et al., 2002).

Many outcome measurement questionnaires are available for the use of people
with hearing impairment, that include International Outcome Inventory for
Hearing Aids (IOI-HA) and Parents' Evaluation of Aural/Oral Performance of

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Children (P.E.A.C.H.). However, up until now, no hearing-specific questionnaire

for adult has been translated and validated into Malay language to our knowledge.
Therefore, in the present study, we describe the protocol used in the translation
and adaptation of the HHIA-M and the preliminary report of the feasibility the
HHIA-M based on findings from both hearing-impaired patients and normal
hearing participants recruited from IIUM Hearing and Speech Clinic.

MATERIALS AND METHODS

HHIA Questionnaire

The HHIA was first developed by Newman et al. (1990) from the modification of
the Hearing Handicap Inventory for Elderly (HHIE; Ventry & Weinstein, 1982).
The HHIA is a self-reported questionnaire designed to assess the hearing handicap
level of hearing-impaired adults. The HHIA has two subscales; social and
emotional. The Social (S) subscale consists of 12-items that are related to the
socializing difficulties due to the hearing impairment whereas the Emotional (E)
subscale consists of 13-items that describe the undesirable emotional impact faced
by the hearing-impaired. Respondents were asked to answer the questions based
on their daily life experience using a 3-likert scale as follows: Yes (4 points),
Sometimes (2 points) and No (0 points). Apart from measuring the handicap
perception level among the hearing-impaired adults, it has been shown to be a
reliable tool for the post-hearing amplification outcome measurement (Newman
et al., 1991).

Subjects

The participants in this study consisted of two groups, the experimental and
control group. For the experimental group, 10 hearing-impaired adults; 5 males
(50%); and, 5 females (50%), age ranging from 22 to 63 (mean = 45.70, SD = 14.85)
participated. The participants were recruited from IIUM Hearing & Speech
Clinic’s registry list. All participants met the same inclusion criteria;(1) hearing-
impaired patients, and; (2) able to understand Malay.

The control group consists of 10 normal hearing adults; 5 males (50%); and, 5
females (50%), age ranging from 24 to 49 years old (mean = 36.60, SD = 8.92). Pure
tone audiometry was conducted on every participant and their hearing level was
normal on both ears and every frequency from 250 to 8000 Hz.

Each of the participants were recruited through convenience sampling. Each of

them was given information regarding the study in written and verbal, and
informed consent was obtained before participating. All participants were
currently employed.

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Translation procedures

The translation process followed the forward-backward method as per suggested

by the Guillermin’s guideline for translation (Guillermin et al., 1993). The
translation procedures were conducted in 4 phases; (1) forward translation; (2)
backward translation; (3) translation review by expert committees; and, (4) initial
testing of the translated questionnaire.

Forward translation
The HHIA was translated from English into Malay by two panellists who have
reasonable knowledge with audiology in general and hearing impairment
specifically. Both panellists were bilingual (Malay and English) native speakers of
Malay. One of the panellists has been working as an audiologist in Brunei, and the
other panellist completed her postgraduate study in the United Kingdom for 2
years and had worked professionally as lecturer in speech-language pathology in
the local university. The two independent translators produced two initial Malay
versions of HHIA, BM1 and BM2. The translators then, together with the first
author discussed and compiled both BM1 and BM2 to be HHIA-M. The compiled
version of HHIA was finalized by choosing the appropriate wording to suite the
Malay semantics and Malaysian culture. The result of the forward translation
produced the Harmonized HHIA-M (BMH).
Backward translation
Next, the BMH was given to another two bilingual native Malay speakers (Malay
and English) and have academic background in teaching English language at least
at secondary level. Both panellists graduated from University of Wellington,
majoring in English education and have been working as English teachers for 6
years. The panellists were blinded to the original HHIA. They were instructed to
translate BMH back into English independently to produce E1 and E2. Next,
comprehensive review and discussion were moderated by the first author, to
produce the initial compiled English version of back-translated HHIA. The
wording and language flow were reviewed by both panellists and the first author
before being finalized into Harmonized English HHIA (EH).

Translation review by expert committees

The EH then was given to the committee together with BMH and all previous
translations of HHIA for further review before proceeding with the pilot testing.
The expert committee was formed of 3 researchers and 2 practicing audiologists.
This process intends to identify flaws which can affect patients’ comprehension,
by focusing on word arrangement and the representation in culture (Beaton et al.,
2000). Based on the discussion, a few alterations were made by the committee to
suite the cultural value in Malaysia while at the same time maintaining the context

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as in the original HHIA. For example, the item ‘I no longer went to watch movies in
cinema or theatre’ was emphasized over the literal translation of ‘cinema’ and
‘theatre’ into ‘I no longer went to watch performance in a closed and surrounded hall’ in
Malay. This is because in Malaysian culture, watching movies and theatres is
uncommon among middle-age adults and elderly. The BMH was concise as literal
as possible to the original HHIA to maintain the context equivalence. Thus, a
satisfactory forward translation was reflected on BMH, producing the initial
HHIA-M.

Test of the initial version of the questionnaires

After approval by the expert committee, the initial HHIA-M was tested on 10
hearing-impaired patients. The participants were briefed regarding the study and
all of them agree to participate voluntarily. The hearing-impaired adult
participants were asked to complete the initial HHIA-M. Time taken by each
participant to answer the questionnaire was noted. A short close-ended question
was asked to all participants; ‘Do you have a problem understanding any word or
sentence in this questionnaire?’, with the choice of answer being only ‘yes’ or ‘no’. All
the hearing-impaired patients answered “yes” to the close-ended question, in all
the HHIA-M questionnaire items.

Statistical analysis

The total score for the questionnaire was calculated by adding the participants’
responses from every item in the HHIA-M. This total score represents the handicap
perception experienced by each participant in both experimental and control
groups.

Normality assumption was not met based on the Shapiro-Wilk’s W test (p<0.05)
and visual inspections to the data through histogram and boxplot. Thus,
comparison between both groups was performed with non-parametric Mann–
Whitney U test.

RESULTS

The HHIA-M scores for the experimental group (better ear threshold, mean = 70.63
dB HL, SD = 26.88) were compared to the control group (average threshold for
both ears less than 20dB). 6 participants had moderate hearing loss (60%), 1 had
severe hearing loss (10%), and 3 had profound hearing loss (30%). The HHIA-M
score was significantly higher in hearing-impaired participants compared with
normal hearing. Table 1 shows that the total HHIA-M score in hearing-impaired
participants ranged from 10 to 70, while all normal hearing participants scored 0.
Median total HHIA-M score was 51 (interquartile range; 10-70) in hearing-

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impaired participants and 0 (interquartile range; 0) in normal hearing (Mann-

Whitney U test, p<0.05).

Table 1: Distribution of responses between experimental and control groups in

HHIA-M total score

Experimental (n=10) Control (n=10)

Yes Sometimes No Yes Sometimes No
Social
S1 3 2 5 0 0 0
S3 4 3 3 0 0 0
S6 3 4 3 0 0 0
S7 4 6 0 0 0 0
S9 2 5 3 0 0 0
S11 2 4 4 0 0 0
S13 2 5 3 0 0 0
S15 3 6 1 0 0 0
S16 2 2 6 0 0 0
S19 1 2 7 0 0 0
S21 3 5 2 0 0 0
S23 2 4 4 0 0 0
Emotional
E2 3 4 3 0 0 0
E4 3 4 3 0 0 0
E5 3 4 3 0 0 0
E8 4 6 0 0 0 0
E10 2 7 2 0 0 0
E12 4 3 3 0 0 0
E14 1 4 5 0 0 0
E17 2 5 3 0 0 0
E18 2 4 4 0 0 0
E20 3 1 6 0 0 0
E22 0 5 5 0 0 0
E24 2 6 2 0 0 0
E25 1 6 3 0 0 0

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DISCUSSION

This article discusses the translation and adaptation of the HHIA-M into Malay
language. This questionnaire was successfully translated into target language with
minor alterations to suit the cultural context (Beaton et al., 2000). In addition, the
HHIA-M was found to be easily administered as it only took about 10–15 minutes
for each participant in experimental group to be completed All participants
reported to have no problem understanding the HHIA-M and no item needed to
be revised based on their feedback suggesting that the HHIA-M is time-wise and
easy to understand.

The hypothesis adopted in the present study was the score in the experimental
group would differ from the score in the control group. Results showed that the
experimental group had significantly higher HHIA-M scores as compared to the
control group. As hearing-impaired patients often reported difficulties in social
activities and emotional impacts as compared to normal hearing people, this key
difference was reflected through the outcome scores of the HHIA-M. This finding
further suggests that the construct of HHIA-M is solely related with the handicap
perception of the hearing-impaired and can be differentiated when a person
without any handicap perception answers the questionnaire. Based on the
preliminary data analysis, it shows the initial evidence that the HHIA-M can
classify patients with hearing impairment from the normal hearing as reported in
the previous studies (Sato et al., 2004; Monzani et al., 2007; Aiello et al., 2011).

CONCLUSION

The findings of this study show that the Malay version of HHIA was easy to
understand and acceptable in Malay-speaking population. Proper validation and
reliability evaluation in larger sample size which includes all races in Malaysia
may be beneficial for future research and for future clinical use of HHIA-M in the
audiology clinic

ACKNOWLEDGEMENT

We express our deepest gratitude to all participants involved in this study. Not to
forget our sincere appreciation to International Islamic University Malaysia for the
research funding provided (RIGS 15-035-0035).

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