Development and Validation of New SubScales for the Hearing Handicap Inventory for Adults and their Relationship

to WHO ICF Constructs

Lauren Miller, M.S., Au.D. Candidate, David Zapala, Ph.D., Mike Heckman, M.S., Department of Otorhynolaryngology Mayo Clinic, Jacksonville, FL
BACKGROUND
The Hearing Handicap Inventory for Adults (HHIA) is a commonly used self assessment questionnaire designed to quantify day to day hearing difficulties. The HHIA includes two subscales to asses the Social and Emotional impacts of hearing impairment (Table 1). 1. 2. 3. We use the HHIA as an adjunct to our audiological evaluation to measure the degree of hearing difficulty a patient may be experiencing as a result of hearing impairment. We are also interested in using the scale as an outcome measure. However, we were unable to find references validating the social and emotional subscales of this questionnaire. The aim of this study was to perform a factor analysis of the HHIA and correlate subscale scores with common audiometric measures of hearing impairment. We also wanted to investigate how the HHIA relates to constructs if disability captured in the International Classification of Functioning, Disability, and Health (ICF; WHO, 2001) by the World Health Organization. 4. 5. 6. 7. 8. 9.

Figure 1: HHIA Questionnaire

Does a hearing problem cause you to use the phone less often than you would like? Does a hearing problem cause you to feel embarrassed when meeting new people? Does a hearing problem cause you to avoid groups of people? Does a hearing problem make you irritable Does a hearing problem cause you to feel frustrated when talking to members of your family? Does a hearing problem cause you to difficulty when attending a party? Does a hearing problem cause you difficulty hearing/understanding coworkers, clients, or customers? Do you feel handicapped by a hearing problem? Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors?

Table 1: Factor Loading on Training group, Validation group, and Combined group

RESULTS
The distribution of age, HHIA total score, and other measures of hearing impairment were very similar between the training and validation groups. Principal component factor analysis of the training group data yielded a two-factor solution; note that when we considered a three-factor solution, the third factor accounted for only 3% more of the variance, and as such a two-factor solution was most appropriate. Factor 1 (F1) was labeled as Difficulty of everyday activities, while Factor 2 (F2) was labeled as Withdrawal from everyday activities and mood changes. These factors replicated remarkably well in the validation group (Figure 2, Table 2), where Lins concordance correlation coefficient on the factor loadings in the two groups was equal to 0.99, indicating near perfect agreement. Combined subscale scores correlated moderately with each accepted audiological measure of hearing impairment, and these results are displayed in Table 3. The traditional social subscale correlated with measures of pure tone hearing sensitivity slightly better than our F1. Since the social subscale reflects multiple underlying factors, assuming this small correlation difference is meaningful, there is likely a multi-factorial relationship between measures of hearing sensitivity and reported hearing problems.

CONCLUSIONS
Based on completed HHIA questionnaires from over 5,000 patients we conclude: The traditional subscales of the HHIA, the social and emotional subscales, are not validly constructed and reflect multiple underlying psychological constructs. Two new subscales, labeled Difficulty of everyday activities and Withdrawal from everyday activities and mood changes, are reliably reflected in patient performance. The new factors relate to aspects of the World Health Organization International Classification of Functioning, Disability, and Health (ICF; WHO, 2001) in a complex way. o o Factor 1, Difficulty of everyday activities, appears conceptually associated with activity limitations and participation restrictions. Factor 2, Withdrawal from everyday activities and mood changes, appears to relate to the degree of self perceived participation restriction. Both factors also appear to reflect self reactions that might fall in the personal ICF category.

METHODS
Design: Retrospective review of HHIA and associated audiometric data from patients seen at Mayo Clinic Florida between 2005 and 2009. (Mayo Clinic IRB 96-06) Data Collection: Analyzed data was collected over two time periods: (1) Training group (2,358 cases) from April, 2005 and November, 2006 consisting of the initial factor analysis and (2) Validation group (2,975 cases) from July, 2007 and September, 2009 consisting of the validation factor analysis (IRB 96-06) Exclusion Criteria: Patients were excluded if (a) the chief complaint was for a non-hearing problem (e.g. dizziness, ear pain), (b) normal hearing as defined by a threshold of 21 dB or better was obtained, (c) their age was less than 21, or (d) there was an incomplete data set. Statistical Analysis: Principal component factor analysis was conducted on the 25 questions of the HHIA using an orthogonal varimax rotation for the training and then the validation group. The number of factors to include was based on examination of eigenvalues from the correlation matrix. An item was considered to load on a factor if the factor loading was 0.40. Lins concordance correlation coefficient was estimated along with a 95% confidence interval to quantify factor loading agreement between the training and validation groups; this correlation coefficient ranges from -1 to 1, with a value of 1 indicating perfect agreement. Additionally, associations between selected audiometric measures (Pure tone average PTA, AAO % Hearing Loss, ASHA % High Frequency Hearing Loss, Word discrimination scores) and subscale scores created from the factor analysis results were analyzed using Pearsons correlation.

10. Does a hearing problem cause you to feel frustrated when talking to coworkers, clients, or customers? 11. Does a hearing problem cause you difficulty in the movies or theater? 12. Does a hearing problem cause you to be nervous? 13. Does a hearing problem cause you to visit friends, relatives, or neighbors less often than you would like? 14. Does a hearing problem cause you to have arguments with family members? 15. Does a hearing problem cause you difficulty when listening to TV or radio? 16. Does a hearing problem cause you to go shopping less often than you would like? 17. Does any problem or difficulty with your hearing upset you at all? 18. Does a hearing problem cause you to want to be by yourself? 19. Does a hearing problem cause you to talk to family members less often than you would like? 20. Do you feel that any difficulty with your hearing limits or hampers your personal or social life? 21. Does a hearing problem cause you difficulty when in a restaurant with relatives or friends? 22. Does a hearing problem cause you to feel depressed? 23. Does a hearing problem cause you to listen to TV or radio less often than you would like? 24. Does a hearing problem cause you to feel uncomfortable when talking to friends? 25. Does a hearing problem cause you to feel left out when you are with a group of people?

Table 2: Degree of association of audiological with the old and new HHIA subscale scores.

The relationship between hearing sensitivity and questionnaire items may be multi-factorial. If the goal of a questionnaire is to predict or verify hearing loss, questionnaire items that best correlate with hearing sensitivity should be selected regardless of the underlying set of psychological constructs measured. The HHIA was created before modern constructs of disability were established (WHO-ICF). Qualitatively, items on the HHIA relate to WHO-ICF constructs of activity limitations (challenges with daily tasks) and participation restrictions (challenges with usual social roles) in a complex way. Hearing is a social sense. Consequently, questions that focus on activity limitations often also imply participation difficulty. Moreover, as a self-report tool, the HHIA measures personal reactions - sometimes explicitly so. It is unlikely that any questionnaire can be constructed that measures hearing loss related activity restriction in isolation. Understanding how HHIA scores relate to ICF constructs is useful in defining what the questionnaire does and does not measure.

Figure 1: Interactions between the components of the WHO International Classification of Functioning, Disability and Health.

Figure 2: Plot of factor loadings for the training and validation groups (n=5333).
1
Factor 1: Difficulty of everyday activities Factor 2: Withdrawal from everyday activities/Mood changes

Health Condition
(disorder/disease)
Validation Group Factor Loading 0.8 0.6

Body function & structure (Impairment)

Activities (Limitation)

Participation (Restriction)

SELECTED BIBLIOGRAPHY
1. Lazaro R, Zapala D, Heckman MG. (2007). Audiometric Correlates and Factor Analysis of the Standard and Modified HHI-A. American Academy of Audiology Annual Convention: AudiologyNOW, Denver, Colorado, 04/2007. Newman, C. W., Weinstein, B. E., Jacobson, G. P., & Hug, G. A. (1990). The Hearing Handicap Inventory for Adults: Psychometric adequacy and audiometric correlates. Ear and Hearing, 11, 430-433. Ventry, I., & Weinstein, B. (1982). The Hearing Handicap Inventory for the Elderly: A new tool. Ear and Hearing, 3, 128-134. World Health Organization (2001). International Classification of Functioning, Disability and Health (ICF). Geneva. World Health Organization. Available at: http://www3.who.int/icf/. 2010 Mayo Foundation for Medical Education and Research 2.

0.4

0.2

Environmental Factors

Personal Factors

0.2

0.4

0.6

0.8

3. 4.

Training Group Factor Loading