Keywords questionnaires - sensitivity and specificity - hearing loss - aging
Palavras-chave questionários - sensibilidade e especificidade - perda auditiva - envelhecimento
Introduction
According to WHO's data, in Brazil, around 2,250,000 inhabitants have a hearing deficit,
corresponding to 1.5% of population[1 ]. To serve this population, the Unified Health System (SUS) launched the Auditory
Health Service comprising a screening and monitoring newborn's hearing and that of
children in kindergarten and at school; a diagnosis of hearing loss in 3-year-old
children or older, teenagers and adults (workers and elderly), meeting the requirements
for each of these conditions[2 ].
Hearing loss can be considered one of the most devastating losses regarding the individual's
social living. In adults, the impact of this type of auditory alteration can be associated
with the cognitive decline, depression and a reduction of the functional state, mainly
for those having loss but who were not evaluated or treated[3 ].
Accordingly, surveying the individuals with a hearing difficulty in a community, their
location and the study of their social conditions are extremely important to fine-tune
the measurements of public health in the several levels of prevention[4 ]. For this purpose, it is fundamental to have methods of auditory screening with
a sensibility to detect a hearing loss in individuals who do not suspect about having
any hearing difficulty and, thus, do not pursue a treatment.
By definition, the screening is applied in a large population, its swiftness and simplicity
in its application, and it must identify the individuals having a high likelihood
of showing a disorder that is being tested[5 ]. The auditory screening, in turn, must have a high sensitivity and specificity to
identify the presence of an auditory alteration when there is really any, as well
as have a low cost[6 ].
The golden test for hearing loss, pure-tone threshold audiometry, requires qualified
personnel, acoustic cabin and specific equipment, making it difficult to be performed
on a large scale basis. On the other hand, the use of questionnaires with a high sensitivity
to indicate hearing loss and that are quickly and cheaply managed, can be a feasible
option to screen hearing in large populations[7 ].
The self-evaluation questionnaires are useful to measure the emotional and social/situational
consequences seen as a result of hearing loss, and they can be used in a wide range
of situations in the clinical routine, such as auditory screening, first interview,
advice, qualification, evaluation, individual's use and satisfaction with the sound
amplification equipment and evaluation of the effectiveness of auditory rehabilitation
programs[8 ]. The Abbreviated Profile of Hearing Aid Benefit - APHAB, The Nursing Home Hearing Handicap - NHHI, The Hearing Handicap Inventory for the Elderly Screening Version - HHIE-S, The Hearing Handicap Inventory for Adults - HHIA, among others, are questionnaires used for this purpose[9 ].
Specifically among these questionnaires, the Hearing Handicap Inventory for the Adults Screening Version - HHIA-S and the Hearing Handicap Inventory for the Elderly Screening Version - HHIE-S, which are smaller versions, respectively, of the do Hearing Handicap Inventory for the Adult - HHIA and the Screening Hearing Handicap Inventory for the Elderly - HHIE, are rapidly applied and easily understood, what enables elderly individuals to use
them. That is the very reason why the HHIE-S questionnaire is recommended by the American Speech-Language-Hearing Association (ASHA) as an auditory screening tool[8 ]
[10 ].
Studies performed abroad by Stewart and cooperators in 2002[10 ], and by Chang , Ho and Chou in 2009[11 ], researched the validity of the HHIE-S and HHIA-S questionnaires with respect to
the perception of hearing loss in the elderly and adults. This study demonstrated
that the questionnaires are highly sensitive and specific in the detection of hearing
loss in this population.
In Brazil, there are currently some studies[8 ]
[12 ]
[13 ]
[14 ]
[15 ]
[16 ]
[17 ]
[18 ] showing the usefulness of participation-restricting questionnaires to identify individuals
with hearing loss and, in Rio Grande do Sul, the HHIE-S questionnaire was used to
evaluate the subjective impact of an auditory rehabilitation program in the elderly[19 ]. On the other hand, there are studies verifying the association between the complaint
and the presence of hearing loss in the elderly[20 ] and showing the prognostic value, sensitivity and specificity of the simple inquiry
about the presence of hearing loss[21 ] in the State of Rio Grande do Sul.
In the first study, individuals answered a demographic questionnaire, in which there
was a list of health problems including hearing loss. Out of the 50 participants,
both sexes, it was noticed that only 12 (24%) had a specific complaint of hearing
loss, although 33 (66%) showed light, moderate, severe and deep hearing loss, and
no association between the complaint and the hearing loss was evident. In the second
one, with a sample of 795 individuals, both sexes and all age groups, 525 (66%) patients
complained about hearing loss, 68 (8.6%) had other auditory complaints, and 202 (25.4%)
had no auditory complaint. The results clearly showed that the complaint about hearing
loss had a sensitivity of 80.9%, specificity of 69.6%, positive prognostic value of
86.5%, and negative prognostic value of 60.4%.
Nonetheless, the use of more comprehensive participation-restricting questionnaires
allows the individual's auditory conditions to be better understood than the mere
inquiry about their auditory condition in both adults and elderly.
The present work, thus, had the objective to verify the sensitivity and specificity
of the HHIA-S and HHIE-S questionnaires to detect a hearing loss and their applicability
in elderly and adult patients' auditory screening based on a sample of individuals
served by SUS at the Audiology Department of Hospital Santa Clara's Otorhinolaryngology
Ambulatory - Santa Casa de Porto Alegre Hospital Complex. Furthermore, as a secondary
objective, the present work attempted to analyze the capacity of the aforementioned
questionnaires to detect different degrees of the studied population's hearing impairment.
Method
This work was approved by Irmandade da Santa Casa de Misericórdia de Porto Alegre
(ISCMPA)'s Ethical Committee in Research under a record number 3292/10, dated of May
10, 2010.
Data collection was performed in a period between May and September 2010, three times
a week, in the afternoon, and it was a transverse section study. The convenience sample
was composed by individuals waiting to perform audiological exams at Hospital Santa
Clara's SUS's Otorhinolaryngology Ambulatory - Complexo Hospitalar Santa Casa de Porto
Alegre.
To be a part of the sample, participants complied with the following inclusion criteria:
be able to read and write, declare to be able and interested in participating in the
research and be 18 years old or older. Firstly, patients signed a Free and Clarified
Agreement Term, authorizing the data collected in this study to be used, in accordance
with the rules established by ISCMPA's Ethical Committee. After signing the term,
the individuals above 60 years of age, i.e., considered elderly by the Ministry of
Health[20 ], answered the HHIE-S questionnaire, and the subjects under 60 years of age answered
the HHIA-S questionnaire.
The questionnaire Hearing Handicap Inventory for the Elderly Screening Version - HHIE-S was developed by Ventry and Weinstein (1982) and customized into Portuguese by Wieselberg (1997) , and the Hearing Handicap Inventory for Adults Screening Version - HHIA-S questionnaire was translated and customized into Portuguese by Almeida (1998).
These tools are comprised of ten questions divided into five items related to social/situation
scale and other five corresponding to the emotional scale. These tools are reduced
customizations of Hearing Handicap Inventory for the Elderly - HHIE and Hearing Handicap Inventory for the Adult - HHIA, hence they are the only equivalent records to be applied to different populations
according to their age group[16 ]. Accordingly, the questionnaires were grouped for data analysis.
The technique chosen to apply the questionnaire was “paper-pencil”, i.e., the individual
was taught how to read and answer the questionnaire by him/herself. However, it was
not possible to use this type of technique with some participants in the sample, thus
the “face-to-face” technique was used, i.e., the oral application of the questionnaire
by the interview only by reading the items, without further explanations or preparations
about them. This was requested or chosen by the individual him/herself in conformity
with what was more convenient to him/her at the time of application, usually due to
visual or reading difficulties. The participants who answered the “paper-pencil” and
“face-to-face” questionnaires were initially analyzed in a separate way.
The likelihood of answers and their score in HHIA-S are identical to those in HHIE-S.
Users were asked to answer “yes” (4 points), “sometimes” (2 points) or “no” (no point)
for each question according to what they deemed to be more appropriate to their case
or situation. The possibility of scores in both questionnaires ranges between 0 (no
participation-restricting perception) and 40 (maximum participation restriction).
Just like what was proposed by Rosis , Souza and Iório
[12 ], individuals were grouped into three categories: 0-8 points (no participation restriction);
10-23 points (light to moderate restriction) and 24-40 points (significant participation
restriction).
Audiometry collection was performed by filling out a questionnaire with the thresholds
of frequencies of 250, 500, 1000, 2000, 3000, 4000, 6000 and 8000 Hz for airways,
and 500, 1000, 2000 and 4000 Hz for bone pathways, in both ears. The audiometric exam
was collected in each patient's record, after it has been performed in accordance
with the usual procedure of the internship of the Phonoaudiology Degree at UFCSPA
at the aforementioned Ambulatory. The equipment used to perform audiometry was Interacoustics AD 227 or Sibelmed AC 50-D.
As to the type of hearing loss, Silman e Silverman
[22 ]'s classification about the types of hearing losses as conductive, sensorineural
and mixed was used. According to the degree of loss, individuals were classified by
taking into consideration the ear with a better hearing, as proposed by Lima , Aiello and Ferrari
[23 ], and Costa , Sampaio and Oliveira
[24 ]. The best ear was used, because the worst ear tends to be compensated by the function
of best size in the subjective perception[7 ]. This classification met BIAP (Bureau Internacional d́Audio Phonologie , 1997)[22 ]'s requirements, which uses the arithmetic average of answers in audiometric frequencies
of 500, 1000, 2000 and 4000Hz and classifies the degrees of hearing loss as: light
(21-40dBNA); moderate with a degree I (41-55dBNA); moderate with a degree II (56-70dBNA);
severe with a degree I (71-80dBNA); severe with a degree II (81-90dBNA); very I (91-100dBNA);
very severe with a degree II (101-110dBNA); very severe with a degree III (111-119dBNA)
and total hearing loss/cophosis (above de 120dBNA).
The comparison of the results achieved between the two forms to apply the questionnaires
(paper-pencil and face-to-face) was performed by Student 's T Test. To verify the association between the variants, the statistical Chi-Square
and Fisher's Exact tests were used, the latter of which was used as an alternative
to Chi-Square, in case the sample is small in some cells of the crossed table.
For all the aforementioned tests, the maximum assumed significance level was 5% (p ≤ 0,05)
and the software used for statistical analysis was SPSS version 10.0.
Results
Sample was comprised of 51 individuals out of whom 49% (n = 25) were female and 51%
(n = 26) were male. Out of the total of study participants, 31,3% (n = 16) were aged
between 18-39, 29,4% (n = 15) were aged between 40-59, and 39.3% (n = 20) were 60
years old or older. The observed average age was 52 with a 16.6-year range (standard
deviation).
As to questionnaires, 60,7% (n = 31) of individuals answered HHIA-S and 39,3% (n = 20)
answered HHIE-S. When comparing both questionnaires, no statistically significant
difference was found between their results (t = 0,22), showing that these records,
even in distinct age groups, can be applied for the same purpose.
In relation to the method of questionnaire application, 55% (n = 28) of individuals
answered in paper-pencil method and 45% (n = 23) answered in the face-to-face method.
There was no statistically significant difference when comparing the methods of questionnaire
application (t =0,16), so the application methods were grouped for analysis.
When it relates to the type of hearing loss, as Silman and Silverman
[21 ]'s classification, 45% (n = 23) of the sample showed a sensorineural hearing loss,
11.7% (n = 6) conductive hearing loss; 11.7% (n = 6), mixed hearing loss, and 31.3%
(n = 16) showed normal hearing thresholds.
In [Table 1 ], the frequency of the different degrees of hearing loss is introduced, taking into
consideration the degree of the best ear, i.e., the one showing the best audiometric
score in accordance with the standards suggested by BIAP[21 ]. Accordingly, it was observed that most individuals had a normal hearing (31.3%)
and a light hearing loss (29.4%).
Table 1.
Frequency of the different degrees of hearing loss in the ear with a better hearing,
found in the participants of the studied sample.
Degree of Hearing Loss
n
(%)
Normal Hearing
16
31,30
Light Hearing Loss
15
29.40
Moderate Hearing Loss with Degree 1
8
15.60
Severe Hearing Loss with Degree 1
2
3.90
Exclusive Hearing Loss at High Frequencies*
10
19.60
Total
51
100
*No classification found in BIAP (1997)'s suggestion: indicates a presence of average
hearing within normal degrees, but the presence of exclusive hearing loss at high
frequencies.
When it relates to the answers achieved in the questionnaires, the sample individuals
were classified as proposed by Rosis , Souza and Iório
[11 ], and the following results were obtained: 29.4% (n = 15) no participation restriction
perceived, 29.4% (n = 15) light to moderate participation restriction and 41.1% (n = 21)
significant participation restriction perceived.
The daily audiological evaluation determined the degree and type of hearing loss;
applied questionnaires evaluated the degree of participation restriction, i.e., the
social and emotional disadvantages as a result of hearing loss in the studied sample.
Based on this, the results of the applicability of HHIA-S e HHIE-S tools were surveyed
with regard to detecting adults and elderly's hearing loss, as well as their ability
to detect different types and degrees of hearing impairment.
In [Table 2 ], an association between the type of hearing loss and the degree of participation
restriction is shown. We observed, in this Table, that there was no significant association
(p = 0.701) between any kind of hearing loss and the presence of any degree of participation
restriction, proving that these questionnaires do not seem to be valid tools to detect
different types of hearing loss.
Table 2.
Association between the type of hearing loss and the degree of participation restriction
in the studied sample.
Degree of participation restriction
Degree of loss
No perception
Light to moderate perception
Significant Perception
Normal Auditory Thresholds
46,7%
23,1%
26,1%
Conductive Hearing Loss
—
15,4%
17,4%
Mixed Hearing Loss
6,7%
30,8%
4,3%
Sensorineural Hearing Loss
46,7%
30,8%
52,2%
Total
100,0%
100,0%
100,0%
(Fischer's Exact Test; p = 0.701).
In [Table 3 ], an association between the degree of hearing loss and the degree of participation
restriction in the studied sample is shown, as per BIAP's classification[22 ]. Based on the result of Fisher's Exact Test, it is once again observed in this table
that there is no significant association between the degree of hearing loss and the
degree of participation restriction.
Table 3.
Association between the degree of hearing loss and the degree of participation restriction
in the studied sample.
Degree of participation restriction
Degree of loss
No perception
Light to moderate perception
Significant Perception
Bilateral Normal Hearing
13.3%
15.4%
4.3%
Unilateral Normal Hearing (with a loss in the other ear)
33.3%
7.7%
21.7%
Light Hearing Loss
20.0%
30.8%
34.8%
Moderate Hearing Loss with Degree 1
6.7%
23.1%
17.4%
Severe Hearing Loss with Degree 1
6.7%
7.7%
—
Hearing Loss in High Frequencies*
20.0%
15.4%
21.7%
Total
100.0%
100.0%
100.0%
(Fischer's Exact Test; p = 0.705).
In [Graphic 1 ], the percentage in individuals with and without hearing loss and with and without
a participation restriction is indicated. In this graphic, it is possible to observe
that 53.3% of the individuals with a hearing disorder and 46.7% of the individuals
having no hearing disorder showed no participation restriction; on the other hand,
75% of the individuals with hearing loss and 25% of the individuals without a hearing
loss showed a participation restriction. By using Chi Square test, it was possible
to observe that there was no significant association between the presence or absence
of hearing loss at any degree and the presence or absence of participation restriction
(p = 0.118).
Graphic 1. Percentage of individuals with and without a participation restriction, in accordance
with the presence or absence of hearing loss in the studied sample (Chi Square; p = 0.118).
To analyze the validity of HHIE-S and HHIA-S questionnaires regarding their sensitivity
and specificity to detect hearing losses and their applicability to screen hearing,
it was investigated how many individuals were properly detected with a hearing disorder,
considering that the accuracy of a test to properly detect positive patients, i.e.,
with a disorder, it is called sensitivity and its accuracy to properly detect the
negative patients is called specificity[12 ].
In the studied sample, it was possible to observe that out of the individuals with
a normal hearing, 9 had and 7 did not have a participation restriction as a result
of hearing disorders that out of the 35 hearing loss participants, 27 showed a participation
restriction and 8 showed none. Accordingly, the tools revealed a low sensitivity (47%),
i.e., individuals with a hearing loss were not identified; however, they showed a
high specificity (75%) by properly identifying the individuals having no hearing disorder.
Discussion
The results achieved in the present study demonstrated the presence of a virtually
equivalent number of men and women and a higher percentage of adult individuals (60.7%)
than elderly (39.3%) in the analyzed sample. It is necessary to emphasize that this
sample was conveniently composed by individuals showing previous hearing complaints;
hence they had been submitted to an audiological evaluation. Therefore, it is assumed
that elderly individuals are served in audiological reference centers other than the
ambulatory where the research was performed, since a higher prevalence of hearing
loss in the senior years is expected[25 ].
When comparing the questionnaires, there was no significant difference between their
results (t = 0.22). This data was expected, because Freitas and Costa
[16 ] claim that these are the only records that are equivalent for application in different
populations, in accordance with age groups. When it relates to the application of
the aforesaid tools, no difference was evident in both types of application, and such
a result was expected because, in another recent research, the application method
did not impact the score achieved in a self-evaluation hearing-related questionnaire[26 ].
As it was verified, sensorineural hearing loss was very prevalent in the studied sample.
This result was foreseen because of the number of elderly individuals composing the
sample, given that in this population the occurrence of presbycusis is prevalent[25 ]. This finding is also compatible with Jardim et al's study[27 ], who equally verified a prevalence of this type of hearing loss in adult and elderly
individuals served in the private department of a Brazilian audiological diagnostic
center.
The frequency of the different degrees of hearing loss shown in [Table 1 ] revealed a higher number of normal hearing individuals, although some of them have
a unilateral hearing loss. It is noticeable that the higher the hearing loss the lower
the number of people; such a fact can be explained by progressive losses characterized
by presbycusis[25 ] shown by the elderly individuals in the studied sample.
With regard to the questionnaire answers, most individuals showed a significant participation
restriction. This was expected because the population involved in the sample showed
previous auditory complaints; hence they mentioned difficulties in accomplishing daily
tasks. Another study performed in São Paulo, also in an audiology ambulatory, found
similar results in percentages[12 ].
In [Table 2 ], no statistically significant correlation between any kind of hearing loss and the
degree of participation restriction was observed. Still in this Table, it is possible
to observe that 23.1% and 26.4% of the individuals with normal auditory thresholds
respectively showed a light to moderate perception and a significant participation-
restricting perception degree. This finding could be explained by alterations in the
auditory processing, because some patients showing audiometry within the normality
standards report auditory complaints about speech clearness as a result of the auditory
processing disorder (APD), what can place a significant effect over the self-evaluation
of the participation-restricting perception[26 ]
[28 ]
[29 ]. Hence, there was a hypothesis that these individuals had no peripheral hearing
loss but complaining about social and emotional changes due to hearing disorders would
possibly have APD.
[Table 3 ] shows there was no significant association between the degree of hearing loss and
the degree of participation restriction (p = 0,705). This finding corroborates with
the literature in the works developed by Araújo et al.
[30 ] and Rosis , Souza and Iório
[12 ] who also observed no association, implying that the perception of the hearing disorder
was not associated with the degree of the hearing loss.
Besides, the tables shown in [Table 2 ] indicate that individuals with light hearing loss show a higher degree of participation-restricting
perception, hence revealing that the degree of hearing loss is not sufficient to prove
a restriction in daily tasks because individuals with light, moderate degree I, severe
degree I hearing loss and at high frequencies can have different degrees of participation-restricting
perception. This result also confirms Correa and Russo
[8 ]'s findings, since, in their research, they verified individuals with light or moderated
hearing loss with a higher degree of participation-restricting perception than individuals
with higher hearing losses.
In [Graphic 1 ], it is possible to observe that 75% of individuals with a participation-restricting
perception showed a hearing loss, and 53.3% of the individuals who did not recognize
this restriction also had hearing losses. This may have happened because many individuals
answered the questionnaire with the adaptations already in practice in their daily
tasks, as mentioned by themselves to researchers during interview. For example, with
reference to question 8 of HHIA-S (“Do you have any difficulty in listening to TV
or radio because of a hearing disorder?”), some people interviewed answered they had
none provided that they would turn up the sound of the equipment.
This study showed that there was no significant association between the presence or
absence of any degree of hearing loss and the presence or absence of a participation-restricting
perception (p = 0.118). This finding matches that of another study[12 ], in which there was no statistically significant association between the result
found in the audiometry and the perception of participation restriction in the individuals
served in the Federal University of São Paulo's Audiology Ambulatory (UNIFESP).
With respect to the sensitivity and specificity to use HHIA-S and HHIE-S questionnaires
to detect hearing loss and their applicability on a screening with adults and elderly
showing hearing disorders, the study implied that these tools do not seem to be good
to detect hearing alterations or screen individuals in audiology services, at which
the patients have hearing-related complaints at arrival, resulting in a low sensitivity
(47%) and a high specificity (75%). This finding confirms another research[12 ], in which HHIE-S questionnaire was also applied, found low values for sensitivity
(23%) and high values for specificity (73.7%), in the group served in an audiology
care center. In this same study[12 ], for a group served in a non-specific audiology disorder-related center, a high
sensitivity (94,7%) and a high specificity (75%) were found, showing that HHIE-S questionnaire
can be valid in this type of population as a screening tool. The findings hereof are
equally supported by the work performed abroad by Gates et al.
[31 ], who observed such results as 35% and 94 % for sensitivity and specificity, respectively,
by using HHIE-S in an elderly population.
Conclusion
In the studied population, the HHIA-S and HHIE-S questionnaires showed a low sensitivity
and a high specificity, proving they are not effective tools to screen individuals
with previous hearing complaints.
Additionally, in this research, these questionnaires did not show they are efficient
to detect different types and degrees of hearing impairment, indicating that the hearing
impairment is not necessarily associated with the type or degree of hearing loss.
