The AIADH, as proposed by Kramer et al.,11 is comprised of 30 questions. Of these, 28 questions are related to five fields of hearing: detection (questions 2, 10, 16, 22, and 28), localization (3, 9, 15, 21, and 27); discrimination/recognition (4, 5, 6, 17, 23, 24, 26, and 29), and intelligibility in silence (8, 11, 12, 14, and 20) and with noise (1, 7, 13, 19, and 25). For each question, there are four alternative answers, “almost never”, “sometimes”, “almost always”, and “always”, scored respectively with values of 3, 2, 1, and 0. The results are interpreted by evaluating the sum of the answers to all questions or by each of the five domains, producing a total and factor scores. A higher score indicates that the patient has greater hearing difficulty in situations dependent on the auditory sensory pathway. Two of the 30 questions – 18 and 30, are not related to the five auditory domains.11,12 However, in this study, they were translated and adapted without having their measures taken, according to other studies on AIADH for other languages.15,21,22

To analyze the instrument's validity and to determine whether it could be used to differentiate between populations with and without hearing loss, we recruited another 31 subjects. All subjects were previously identified with hearing loss by the public health system, and were referred to the Hearing Health Program of the Medical School of Ribeirão Preto-University of São Paulo.

The inclusion criteria were: a minimum age of 18 years, with no upper age limit; the presence of post-lingual acquired hearing loss of any nature; no previous experience of sound amplification devices; no apparent symptoms of conditions affecting communication observed during spontaneous conversation; and no need for caregivers and/or aids for locomotion and/or activities of daily living. This information was verified with a companion, when present. We did not establish exclusion criteria for this stage. The presence of hearing loss was identified when the mean frequencies of 0.5, 1, 2, and 4kHz were >20dB HL.24

The Pt-AIADH was performed by a single researcher on two days with the same subjects, with a minimum interval of 30 days between the interviews, to examine the test-retest reproducibility (reliability).

Thereafter, we compared the Pt-AIADH scores between subjects with and without hearing loss (Hearing Loss Group, HLG and Normal Hearing Group, NHG). The HLG was comprised of 31 volunteers from Study 2; the NHG was comprised of 18 of the 25 subjects from Study 1, Stage 4, who corresponded to those with mean tonal thresholds within normal limits for both ears.

We used the Kappa concordance test in Stage 1 and 2 of Study 1.

In Study 2, the reliability of the Pt-AIADH was estimated using the Cronbach's alpha coefficient (α) test by question and domain. We used the Guttman Split-Half coefficient test25 to calculate the correlation between the two-part measures of the instrument (first 15 questions vs. last 15 questions). Reproducibility was determined by the degree of intraclass correlation within each domain (intraclass correlation coefficient) using an analysis of variance. The coefficient was estimated based on the mean squares obtained with the following formula: rI=Sb2−Sw2Sb2+(n−1)Sw2; in which Sb2 is the mean square because of variation between classes, Sw2 is the average square because of variation within classes, and n is the number of measurements within each class.

To verify whether the pure tone averages of the groups with and without hearing loss were different within and between the two groups for the different scores, we used the Mann–Whitney test. Finally, we estimated the correlation between values of the tonal means and total score using the Pearson's correlation test.

All analyses were performed with a 5% significance level and adjustments were performed using SAS Version 9.2 and R version 3.1; Prism 7 was used to produce graphs.

The analysis of the agreement among the three versions of the AIADH translated into Portuguese (Study 1, Stage 1), as well as between the original instrument and the resultant back-translation into Portuguese (Study 1, Stage 2) exhibited a level 1 agreement.

The Portuguese version 1 of the AIADH was studied by the review committee for its grammatical and cultural adaptation (Study 1, Stage 3), which generated the adapted version 1. Fig. 1 presents two examples of the need for cultural adaptation.

Figure 1.

Example of two questions of the English version of AIADH that required cultural adaptation to Brazilian Portuguese.

(0.23MB).

The adapted version 1 was applied in a pre-test condition in 25 subjects with a mean age of 34 years (54.5% women). The calculation of the mean tonal thresholds suggested hearing loss in some subjects (Table 1). All 25 subjects answered the 30 questions; 100.00% of them said that there was no difficulty in answering or understanding the questions. Additionally, there were no requests to repeat any questions.

The described results enabled the identification the instrument as the Pt-AIADH (Appendix 1).

The Pt-AIADH was applied to 31 subjects, with a minimum age of 25 and a maximum of 92 years (mean=59 years; SD=21.4). All subjects presented with hearing loss, thus constituting the group with Hearing Loss (HLG), with 74.2% (23/31) and 25.8% (8/31) being of the sensorineural and mixed types, respectively. Concerning laterality, 96.8% (30/31) had bilateral impairment and only 3.2% (1/31) demonstrated unilaterality. The descriptive values of the tonal means are shown in Table 1.

The Pt-AIADH responses were studied in relation to their reliability. Internal consistency was the first variable examined. We initially performed the calculation for each of the 30 questions separately, then for each of the domains, and later the instrument. Next, the correlation between the two halves of the questionnaire was calculated. For these analyses, the lowest value was always ≥0.80, except for the result of the analysis of the second part of the inventory, which was 0.72 (Table 2).

Table 3 shows the reliability measures obtained from the present version as well as the other measures already taken from AIADH to facilitate visualization and comparison.

The second variable analyzed for reliability was the intrasubject reproducibility (i.e., test/retest reliability); 100.00% of the 31 subjects with hearing loss responded to the Pt-AIADH at two time points, the score results at the two points were similar, if not equal (Table 4). The interval between the first and second interview ranged from 30 to 55 days (mean=40 days; SD=10). The intraclass correlation between the test and retest was estimated and yielded the following results: detection=0.94 (min=0.90, max=0.98); localization=0.99 (min=0.99, max=0.99); discrimination=0.91 (min=0.86, max=0.97); speech intelligibility in quiet=0.98 (min=0.97, max=0.99); speech intelligibility with noise=0.98 (min=0.97, max=0.99); and total score=0.97 (min=0.96, max=0.99).

Correlations among the five domains of Pt-AIADH were also calculated (Table 5). The results suggest that there is a moderate correlation among the domains, with only one exception, found between the auditory location and speech perception in silence.

Subsequently, we conducted a study to verify whether the instrument differentiated groups with and without hearing loss (HLG and NHG, respectively). The HLG comprised 31 subjects from Study 2, while the NHG comprised 18 (72.00%) of the 25 subjects in Study 1, Stage 4 of the pre-test phase, who corresponded to those subjects with mean tonal thresholds within normal limits.

Initially, we analyzed how different the tonal means were between the two groups. The HLG exhibited values of tonal means of the best and worst ear inferior to those of the NHG (mean of the best ear HLG vs. NHG, p<0.0001*; U′=32; mean of the worst ear HLG vs. NHG, p<0.0001*; U′=0) (Table 1).

Next, the results of the total Pt-AIADH scores and of each of its domains (detection, localization, discrimination/recognition, and intelligibility with and without noise) were compared between the two groups. For all domains, significant differences (p<0.0001*) were observed, showing that the HLG presented greater hearing difficulty than did the NHG (Fig. 2). Finally, we identified the correlation between the tonal mean values of the subjects (with and without hearing loss, n=49) with the total Pt-AIADH score. We used the corresponding tonal means of the best ears of the two groups and found a strong significantly positive correlation (r=0.8303, p<0.001*, 95% CI 0.7207–0.8994); briefly, the higher the tonal mean, the greater the hearing difficulty (Fig. 3).

Figure 2.

Mean values scores for each of the auditory factors, as total, of the Pt-AIADH in Normal Hearing Group (NHG) and Hearing Loss Group (HLG).

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Figure 3.

Means of the pure-tone (across 0.5, 1, 2 and 4kHz of the better ear) and total score obtained in both groups, with and without hearing loss (n=49).

(0.04MB).

The analysis of the agreement between judges concerning the three independent translations, as well as the back-translation, was selected to produce greater reliability, as recommended by the specialized literature.10 The degrees of agreement obtained at this stage were the largest possible, allowing the Portuguese version 1 of the AIADH to move to the grammatical and cultural adaptation stage, generating an adapted version 1, an essential step because it allows certain phenomena, such as self-reported hearing loss in this study, to be identified in different cultures.6,8,10 With the adapted version, we evaluated the first of four validation criteria, instrument acceptance.6,7 In the pre-test stage, none of the volunteers reported that they did not understand any of the 30 questions, which allowed the Pt-AIADH version to be finalized, suggesting that it is a feasible instrument.

The Pt-AIADH was established in an interview conducted with 31 subjects with hearing loss, with the objective of evaluating their reliability in terms of internal consistency and reproducibility, criteria two and three of the validation process.6

The AIADH is a multidimensional instrument because there are five factors,2 so therefore, it is necessary to evaluate all the factors and not only the total score.6

The isolated results that we obtained from the Pt-AIADH suggest that it contains sufficient reliability for its use, because the literature indicates that α=0.70 is a suitable cut-off, with α=0.90 considered excellent25,26; our values here ranged from 0.72 to 0.94. A limiting factor in the results presented in this study is the absence of a factor analysis, as carried out in the original study and in the Swedish version.15 The referred analysis would enable to identify whether the AIADH questions would present the same underlying structure,27 nonetheless, the Pt-AIADH sample number did not enable its calculation. This also occurred for the other versions, which did not carry out the same analysis factor. On the other hand, although a factor analysis is lacking, the absence does not undermine the results obtained from the measurements of the other construct variables, which are quite satisfactory.25,26

When we compared these results with translations of the AIADH into Swedish, Cantonese, and Spanish, it was possible to verify that the reliability values are similar, and that they may be interpreted as satisfactory results.15,21,22

All measures of the intra-observer reproducibility of Pt-AIADH showed favorable results concerning the stability of the instrument, as well as similarity to other versions in other languages.15,21,22

The potential for translating and culturally adapting PROMs from English to Brazilian Portuguese, while maintaining validation measures of the respective instruments, is precedented.28–30 Castro et al.28 examined an inventory for subjects with dizziness, the Dizziness Handicap Inventory, while Mondelli et al.29 examined the Satisfaction with Amplification in Daily Life applied in 30 subjects with hearing loss who used acoustic amplification. In both cases, the authors translated and adapted the respective instrument; however, they evaluated only one aspect of reliability, reproducibility. However, in the translation and adaptation of Beliefs and Attitudes on Hearing Loss Preventions to Brazilian Portuguese, Bramatti et al.30 evaluated more validation questions, such as the construct, and the results yielded values that give confidence to use the respective instrument.

The use of Pt-AIADH in subjects with and without hearing loss yielded distinct results between them, that is, it could distinguish the condition for which it was constructed. The higher the averaged pure tone thresholds, the greater the self-reported hearing difficulty, consistent with studies of the AIADH translated and adapted into other languages.15,21,22 These measures are important because clinical tests for auditory measurement do not encompass daily activities in which the subject is involved.

It is important to emphasize that no Portuguese PROM aimed at examining hearing, focusing on the hearing difficulty, with known validation variables presented, has been developed. This makes the Pt-AIADH the first reliable instrument for its purpose, available in Brazilian Portuguese. Lastly, as a final consideration, we emphasize that future studies should characterize domains according to audiometric characteristics, as well as the sensitivity and specificity of the instrument.