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This is to certify that the
thesis entitled

TEST—RETEST RELIABILITY AND CLINICAL
UTILITY OF THE MULTIMEDIA HEARING
HANDICAP INVENTORY

presented by

Sara Louise Shogren

has been accepted towards fulfillment
of the requirements for

M-A- degree in _ASC___

Qég/xr

V

Major professor

Date 05112199

0-7639 MS U is an Affirmative Action/Equal Opportunity Institution

TEST-RETEST RELIABILITY AND CLINICAL UTILITY OF THE
MULTIMEDIA HEARING HANDICAP INVENTORY

By

Sara Louise Shogren

A THESIS

Submitted to
Michigan State University
in partial fiilfillment of the requirements
for the degree of

MASTER OF ARTS

Department of Audiology and Speech Sciences

1 999

ABSTRACT
TEST-RETEST RELIABILITY AND CLINICAL UTILITY OF THE
MULTIMEDIA HEARING HANDICAP INVENTORY
By
Sara Louise Shogren

A new multimedia version of the Hearing Handicap Inventories (MHHI) was
recently developed by Punch and Weinstein based on the original screening versions of the
Hearing Handicap Inventory for the Elderly (HHIE - S) and the Hearing Handicap
Inventory for Adults (HHIA-S). The MHHI is comprised of two separate programs: a
short program (SP) and a long program (LP). The purpose of this study was to determine
the clinical utility of the MHHI, including its test-retest reliability, acceptability and ease of
use, and preliminary clinical validity.

Thirty-six normal-hearing and hearing-impaired subjects completed the MHHI
during two separate test sessions conducted three weeks apart. Audiometn'c data and case
history information were collected in both sessions. Each subject was randomly assigned
to one of three test-retest sequences (LP/ SP, SP/ SP, or SP/LP).

Results revealed the MHHI to have high test-retest reliability and high internal
consistency reliability. Statistical properties were shown to be highly consistent with those
of the original screening versions of the HHI. Overall, the MHHI exhibited good clinical
utility. Its full validation as a screening measure of hearing impairment will require testing

with a larger number of subjects than included in this study.

Copyright by

SARA LOUISE SHOGREN
1999

This is dedicated to Kenneth Shogren, Daniel Shogren, Jennifer Rise, and most especially
David and Virginia Shogren. They have always given their love and support and never let
me lose sight of my dreams.

iv

ACKNOWLEDGMENTS

I extend my sincere gratitude to Dr. Jerry Punch, chairperson of my master’s thesis
committee, for all his time, energy, commitment, and mentoring throughout my graduate
studies, and especially throughout this thesis.

Appreciation is also extended to Dr. Jill Elfenbein and Dr. Brad Rakerd, members
of my thesis committee, for their insightfirl perspectives and comments which were
invaluable to this project. Also, gratitude is extended to Dr. Frank Biocca for his advice in
the initial planning stage of this project.

I wish to thank Patti Hergenreder for assisting with the recruitment of subjects. A
special thanks is due to the East Lansing Senior Center for allowing me to talk briefly
about my project to potential subjects. Appreciation is also extended to Kathy Scieszka
and Andrea Pirochta, who also helped with the recruiting of subjects.

I am especially grateful to all the participants in this project who donated their time
to participate in this experiment. The project could not have been completed without
them.

Appreciation is extended to Kenneth D. Shogren who provided much-valued
mathematical and statistical advice, as well as formatting guidance.

Lastly, thanks to Lara L. Gingerich and Amyn M. Amlani, who provided advice,

encouragement, and understanding throughout this project.

TABLE OF CONTENTS

LIST OF TABLES ________________________________________________________________________________________________________________ viii
LIST OF FIGURES _________________________________________________________________________________________________________________ x1
CHAPTER 1 - BACKGROUND _____________________________________________________________________________________________ 1
CHAPTER 2 - REVIEW OF LITERATURE _______________________________________________________________________ l 7
Hearing Handicap Inventory for the Elderly _____________________________________________________________ l 7
Hearing Handicap Inventory for Adults ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 25
Multimedia Hearing Handicap Inventory __________________________________________________________________ 28
CHAPTER 3 — METHOD ______________________________________________________________________________________________________ 34
Overview _____________________________________________________________________________________________________________________ 34
Subjects _______________________________________________________________________________________________________________________ 34
Test-Retest Sequences ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 41
Audiologic Evaluation ................................................................................................ 4 2
Interview Materials _____________________________________________________________________________________________________ 4 3
Procedures .................................................................................................................. 47
CHAPTER 4 - RESULTS AND DISCUSSION __________________________________________________________________ 53
Overview ..................................................................................................................... 53
Hearing Sensitivity Across Subject Groups ______________________________________________________________ 54
Descriptive Analysis of MHHI ................................................................................... 55
Test-Retest Reliability ________________________________________________________________________________________________ 55
Internal Consistency Reliability __________________________________________________________________________________ 6 0
Cfitical-Diflemnce Scores __________________________________________________________________________________________ 66
Predictive Validity ______________________________________________________________________________________________________ 67
Subject Choices on the MHHI ................................................................................... 77
Exit-Questionnaire Analysis _______________________________________________________________________________________ 79
CHAPTER 5 - CONCLUSION _____________________________________________________________________________________________ 86
APPENDICES ........................................................................................................................ 90
Appendix A - Hearing Handicap Inventory for the Elderly (HHIE) _____________________ 91
Appendix B - Hearing Handicap Inventory for the Elderly -
Screening Version (HHIE-S) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 94
Appendix C - Hearing Handicap Inventory for Adults (HHIA) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 96
Appendix D - Hearing Handicap Inventory for Adults —
Screening Version (HHIA - S) ___________________________________________________________ 99
Appendix E - Components of the Long Program of the MHHI ,,,,,,,,,,,,,,,,,,,,,,,,,,,, 101

Appendix F - Components of the MHHI Hearing Profile ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Appendix G - Protocol Design for Eight Hearing Profiles ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Appendix H - F irst-Session Case History Form _____________________________________________________
Appendix I - Second-Session Case History Form. ................................................
Appendix J - Exit Questionnaire - Long Program (LP/SP

and SP/LP Sequences) _____________________________________________________________________
Appendix K - Exit Questionnaire - Short Program

(SP/SP Sequence) ............................................................................

REFERENCES

ooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo

102
103
112
114
116
119

122

LIST OF TABLES

Table 1.] - History and scope of Hearing Handicap Inventories ...................................
Table 2.1 - Hearing Profile contingencies ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

Table 3.1 - Distribution of male and female subjects in each test group,

________ 7

30

subdivided by adult subjects (MHHI-A) or elderly subjects (MHHI-E) ,,,,,,,,,, 35

Table 3.2 - Means and standard deviations for subjects, subdivided by inventory,

gender, experimental group, and age ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

Table 3.5 - Bases for eliminating subjects fiom test-retest reliability analysis and

validity analyses, based on first case history ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

Table 3.6 - Bases for eliminating subjects from test-retest reliability analysis,

based on second case history or audiornetric data ......................................

Table 4.1 - Means, standard deviations, and 95% confidence intervals for test

and retest conditions for MHHI, MHHI-E, and MHHI-A .........................

Table 4.2 - Means, standard deviations, and 95% confidence intervals for three

exocrimemal grouos ......................................................................................

Table 4.3 - Pearson product-moment correlations for MHHI, MHHI-E, and

MMHI-A, based on emotional score, social score, and total score ,,,,,,,,,,,

Table 4.4 - Pearson product-moment correlations for three experimental groups,

based on emotional score, social score, and total score _____________________________

Table 4.5 - Pearson product-moment correlations for male and female subjects,

based on emotional score, social score, and total score ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

Table 4.6 - Pearson product-moment correlations for subjects subdivided by
age group and gender, based on emotional score, social score,
and total score

ooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo

Table 4.7 - Cronbach’s alpha for the MHHI by test and retest administration

and major subject subgroup ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

Table 4.8 - Cronbach’s alpha for three experimental groups, subdivided by
test and retest administrations, adult and elderly subjects, and

inventory subscales ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

Table 4.9 - Cronbach’s alpha for two versions of the MHHI (short and long
programs), for test and retest administrations in difl‘erent

experimental groups _____________________________________________________________________________________

Table 4.10 - Cronbach’s alpha for the MHHI-E and MHHI-A and the short

and long programs of the MHHI ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Table 4.11 — Critical-difference scores (95% confidence interval) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

Table 4.12 - Sensitivity, specificity, false-positive, and false-negative rates
using an MHHI cutoff score of 2, for various definitions of hearing

I ...................................................................................................

...........................................................................

Table 3.4 - Subjects’ annual net incomes ........................................................................

36

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56

57

......

59

59

59

60

62

63

...... 64

65
67

69

Table 4.13- Sensitivity, specificity, false,-positive and false-negative rates
using an MHHI cutofl‘ score of 4, for various definitions of hearing

impairment _________________________________________________________________________________________________________ 6 9
Table 4.14- Sensitivity, specificity,false-positive and false-negative rates

using an MHHI cutofl‘ score of 8, for various definitions of hearing

inmairment ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 70
Table 4.15- Sensitivity, specificity, false,-positive and false-negative rates
using an MHHI cutofi' score of 10, for various definitions of hearing

impairment ......................................................................................................... 70
Table 4.16- Sensitivity, specificity, false-positive, and false-negative rates

using an MHHI cutofl‘ score of 16, for various definitions of hearing

impairment ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 71
Table 4.17- Sensitivity, specificity, false,-positive and false-negative rates
using an MHHI cutofl‘ score of 24, for various definitions of hearing

impairment ........................................................................................................ 71
Table 4.18— Correlations between MHHI scores and selected audiometric indices 72

Table 4.19 - Mean MHHI scores and standard deviations for normal-hearing and
hearing-impaired subjects, as classified by Speech Reception Threshold
(SRT) with 20-dB HL cutofi‘ 74

ooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo

Table 4.20 - Mean MHHI scores and standard deviations for normal-hearing and
hearing-impaired subjects, as classified by Speech Reception Threshold
(SRT) with 25-dB HI. cutofi' 75

Table 4.21 - Mean MHHI scores and standard deviations for normal-hearing and
hearing-impaired subjects, as classified by Word Recognition Score
(WRS) ............................................................................................................... 75
Table 4.22 - Mean MHHI scores and standard deviations for norrml—hearing and
hearing-impaired subjects, as classified by Speech Frequency Pure
Tone Average (SFPT A) with 20-dB HL cutoff 75

ooooooooooooooooooooooooooooooooooooooooooooo

Table 4.23 - Mean MHHI scores and standard deviations for normal-hearing and

hearing-impaired subjects, as classified by Speech Frequency Pure
Tone Average (SFPTA) with 25-dB HL cutofl‘ 76

ooooooooooooooooooooooooooooooooooooooooooooo

Table 4.24 - Mean MHHI scores and standard deviations for normal-hearing and

hearing-impaired subjects, as classified by High Frequency Pure
Tone Average (HFPT A) with 20-dB HL cutofi‘ 76

ooooooooooooooooooooooooooooooooooooooooooooo

Table 4.25 - Mean MHHI scores and standard deviations for normal-hearing and
hearing-impaired subjects, as classified by High Frequency Pure

Tone Average (HFPT A) with 25-dB HL cutoff ___________________________________________ 77
Table 4.26 - Subjects’ use of the Computer Introduction section of the MHHI _________________ 78
Table 4.27 - Exit»questionnaire results for subjects administered only the short

program (SP/SP) ............................................................................................... 80
Table 4.28 - Exit-questiomiaire results for subjects administered the long program

in either session (LP/SP 0r SP/LP) ................................................................. 81

Table 4.29 - Comfort level reported with selected technologies by subjects

performing the short program only (SP/SP) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Table 4.30 - Comfort level reported with selected technologies by subjects

performing the long program in either session (LP/SP or SP/LP) ________________
Table 4.31 - Spearman rho’s for utility, income, education, and technology

comfort for the SP/SP test group ___________________________________________________________________
Table 4.32 - Spearman rho’s for utility, income, education, and technology

comfort for the LP/SP and SP/LP test 8r0t1ps ...............................................

82

84

85

LIST OF FIGURES

Figure 3.1 - Mean air-conduction audiometric thresholds for the better ears
of experimental groups. Each group included 12 subjects, six of
whom were adults and six of whom were elderly adults, classified

as described in the text. ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 38

Figure 3.2 - Mean air-conduction audiometric thresholds for the better ears
of adult and elderly adult subjects. Each group included 18 subjects. ____________ 39

Figure 3.3 - Mean air-conduction audiometric thresholds for the better ears
of male and female subjects. Each group included 18 subjects, _______________________ 40

Chapter 1

Background

Hearing disability has been characterized as encompassing the primary
communication consequences of a hearing loss, and a handicap as encompassing the
secondary consequences of a hearing loss. In recent years, distinctions have been drawn
among the terms disorder, impairment, disability, and handicap:

“A hearing disorder occurs as a result of some type of
disease process or malformation of the auditory system.

A hearing impairment is any loss or abnormality of
psychological, physiological, or anatomical structure or function.

A hearing disability is any restriction or lack (resulting from
an impairment) of ability to perform an activity in the manner or
within the range that is considered normal for a human being.

A hearing handicap is a disadvantage for a given individual,

resulting from impairment or disability, that limits or prevents the

fiilfillment of a role that is normal (depending on age, sex, and

social and cultural factors) for that individual.”

(World Health Organization, 1980)

A disorder, impairment, or disability can be characterized or reasonably predicted
by use of audiological measures such as pure tone audiometry, speech recognition
thresholds, acoustic reflex thresholds (ART), otoacoustic emissions (OAE), and auditory
brainstem responses (ABR), but the handicapping, or secondary, effects of a hearing loss
need to be measured with different tools. One way to quantify handicap is to use a formula

developed by the American Academy of Otolaryngology (AAO) Committee on Hearing

and Equilibrium (1979). The AAO formula classifies people as either handicapped or not

handicapped according to a formula based on thresholds for the frequencies 500 Hz, 1000
Hz, 2000 Hz, and 3000 Hz, with a cutoff of 25 dB HL.

Self-assessment scales, inventories, or questionnaires provide another way to
measure hearing handicap. Self-assessment data reveal important insights about
individuals’ responses to hearing impairment that cannot be gleaned from audiometric data
(Weinstein and Ventry, 1983). Hearing handicap represents the non-auditory problems
resulting from hearing disorder, impairment, or disability. While the degree of hearing
handicap generally increases with increased hearing impairment, hearing handicap may
vary, depending on the attitudes and perceptions of the affected individual and those with
whom he or she interacts, as well as with the demands placed on one’s ability to hear and
understand speech in everyday life. Individual response is based on personality,
psychosocial adjustment to a hearing impairment, age, and general health (Ventry and
Weinstein, 1982).

Self-assessment inventories have been designed to assess hearing handicap in the
young adult and elderly adult populations. They assess various aspects of a hearing loss,
including attitudes, general communication abilities, communication in various
environments or situations, emotional aspects of a hearing loss, and the effects of hearing
loss on social functioning. As many as 158 items and as few as 5 items have been used to
evaluate the various consequences of hearing loss on everyday life. A comprehensive
listing of self-assessment inventories is given in Table 1.1. This listing describes the target

population, the author/developers(s), the year the inventory was published, the number of

items in the inventory, the factors measured, and (if available) the approximate time
required to complete the inventory.

Self-assessment scales in audiology have evolved from pencil-and-paper versions
in the mid-19603 to current scales that are administered through computer technology. A
similar transition to computer technology has been seen in the field of psychology.
Psychological questionnaires were computerized for two reasons: 1) for ease of scoring
and 2) to elicit more-honest responses from subjects than are likely to occur on written
questionnaires or in face-to face interviews. Neal, Fox, Carroll, Holden, and Barnes
(1997), in a study involving a computerized version of a personality disorder screening
test, indicated the need for greater ease in scoring questionnaires. They noted that
“computerized tests based on self-report questionnaires should be independently validated
because reliability between the two forms cannot automatically be assumed” (Neal et. al,
1997, p. 352). Skinner and Allen (1983) speculated while analyzing a computer version of
a self-assessment questionnaire that more-accurate information would be provided about
sensitive areas. In their study of alcohol, drug, and tobacco use, they found no difference
in reliability, level of problems reported, or consumption patterns among a computerized
version, a pencil-and-paper version, and a face-to-face version. Pouwer, Snoek, van der
Ploeg, Heine, and Brand (1998) found no differences in computerized and pencil-and-
paper versions of the Well-being Questionnaire (WBQ) and the Diabetes Treatment
Satisfaction Questionnaire (DTSQ) and thus considered the versions to be equivalent.

However, Duijsens, Eurelings-Bontekoe, and Diekstra (1996) found only a moderate

agreement between the computerized Vragenlij voor Kenmerken van de Persoonlijkheid
(VKP), an instrument for determining personality disorders, and their gold standard scale.

The Multimedia Hearing Handicap Inventory (MHHI) is one of the newest self-
assessment scales in Audiology. It is a computerized, multimedia questionnaire based on
paper-and-pencil screening questionnaires. The purpose of this study was to evaluate the
test-retest reliability and overall clinical utility of the MHHI.

Self-assessment scales serve multiple purposes beyond the measurement of hearing
handicap. They may be used to screen directly for hearing handicap; screen indirectly for
hearing impairment; evaluate the need for aural rehabilitation, including hearing aid
candidacy; measure outcomes of audiological interventions, such as hearing aid benefit;
and market and promote one’s clinical practice.

When self-assessment scales are used to screen for hearing handicap or
impairment, it can generally be presumed that patients who score on one side of a
specified cutoff value will not exhibit a hearing impairment, while patients scoring on the
other side of that cutoff value will exhibit hearing impairment. To the extent that this is
true, the scale may be said to be a valid screening measure of hearing handicap or hearing
loss. If a patient’s score on such a scale suggests no handicap, it may also be presumed
that hearing aids and other forms of aural rehabilitation are not necessary. On the other
hand, if the score of a patient who does not wear amplification suggests hearing handicap,

aural rehabilitation (probably hearing aids) will likely need to be considered.

Ideally, predictions of who will pursue amplification and actually use it may also be
gleaned from self-assessment scales. If a patient demonstrates a low handicap score,
despite audiometric evidence of hearing impairment, the patient is not perceiving a hearing
handicap. Because that individual does not regard hearing to be a problem, he or she is not
likely to seek assistance, and is also unlikely to comply with specific recommendations to
do so. On the other hand, the patient who demonstrates both audiometric hearing loss and
a high handicap score perceives hearing to be handicapping and is likely to comply with
recommendations to explore amplification or other forms of audiologic rehabilitation.

Given a high test-retest reliability and validity, a self-assessment scale may be used
effectively as an outcome measure. If a handicap score on such a scale decreases
substantially over a time period in which the patient undergoes some rehabilitation
process, then it may normally be assumed that the process is largely responsible for the
patient’s perception of diminished handicap.

Self-assessment scales may be utilized in various settings. If the scales are
relatively easy to use, easy to score, have validity and high test-retest reliability, and
provide a basis for determining candidacy for—and benefit from—rehabilitation, they may
be used to promote one’s clinical practice. For example, a potentially powerful strategy
for the use of self-assessment questionnaires would be their use in offices of primary-care
physicians to refer patients to audiologists for diagnostic services and follow-up care.

Due to the wide variety of uses for self-assessment scales, the development and

improvement of these scales is a highly worthwhile task. The present study focused on a

preliminary evaluation of the MHHI. Because the Hearing Handicap Inventory for the
Elderly-Screening Version (HHIE-S) and the Hearing Handicap Inventory for Adults-
Screening Version (HHIA-S) are important components of the MHHI, these two scales,
their parent scales (HI-11E and HHIA), and the MHHI itself will be the major topics

addressed in the Review of Literature in the next chapter.

 

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16

Chapter 2

Review of Literature

Hearing Handicap Inventory for the Elderly

Ventry and Weinstein (1982) developed the Hearing Handicap Inventory for the
Elderly (HHIE; Appendix A) to assess the emotional and social adjustment of elderly
people (age 65 years or older) to a hearing loss. It is comprised of two subscales:
emotional reactions to a hearing loss (emotional subscale) and how social situations are
affected by a hearing loss (social-situational subscale) to conform to their hypothesis that
a hearing impairment becomes a hearing handicap “when it affects behavior and when it
affects the emotional well-being of the hearing-impaired person.” (Ventry and Weinstein,
1982, p. 129). Thirteen of the 25 questions assess social-situational reactions (abbreviated
S), and the remaining 12 assess emotional reactions (abbreviated E). Respondents are to
answer Yes, Sometimes, or No to each question. A hearing handicap score is calculated by
summing all responses, where each Yes response is worth 4 points, each Sometimes
response is worth 2 points, and each No response is worth 0 (zero) points. Scores for each
subscale (S and E) can be calculated separately and/or conjointly. A Not Applicable
category is not included as a possible response. Although all emotional questions would be
applicable, not all situations may be applicable to every individual. Respondents are
encouraged to answer even those questions involving situations that they either avoid or

do not experience. In essence, they are encouraged to respond as if they were to engage in

17

those specific activities. The maximum score on the I-IHIE is 100 points. The higher the
patient’s score, the more the patient perceives a hearing handicap. An I-II-IIE score of 16
or less, or 16% or less, is taken to indicate no handicap, 17%-42% represents a mild
handicap, and a score of 43% or greater indicates a significant handicap (Weinstein and
Ventry, 1983). A score of 18 or greater, therefore, is indicative of a substantial self-
perceived hearing handicap.

The Hearing Handicap Inventory for the Elderly—Screening version (HHIE-S;
Appendix B) is an abbreviated version of the HHIE (Ventry and Weinstein, 1983). It
consists of 10 questions, compared to the 25 questions of the HHIE. The two sub-
categories, emotional and social-situational reactions to a hearing loss, are still represented
in the screening version, and scoring is performed in essentially the same way as for the
HHIE. The highest possible score on the HHIE-S, however, is 40. A cutoff of 8 is used to
distinguish those who do not have a hearing handicap from those who do. Scores of 0-8
represent no perceived handicap, while scores of 10-40 represent proportionally higher
degrees of perceived handicap. In a study of the validation of screening tools by
Lichtenstein, Bess, and Logan (1988b), subjects with an HHIE-S score of 0-8 had a 13%
probability of having a hearing impairment, scores of 10-24 were associated with a 50%
probability of having a hearing impairment, and scores of 26 or more were associated with
an 84% probability of having a hearing impairment. The sensitivity, the degree to which a
measure correctly identifies impairment, and the specificity, the degree to which a measure

correctly identifies the absence of impairment, were evaluated against Ventry and

18

Weinstein’s (1982 and 1983) pure tone criteria. Those pure tone criteria were defined as
follows: a subject had a hearing impairment if the subject had a hearing loss of 40 dB HL
or greater for either 1000 or 2000 Hz in both ears, or the subject had a hearing loss of 40
dB HL or greater at 1000 and 2000 Hz in the same ear. With a score of 8 as a cutoff
point, the HHIE-S had sensitivities ranging from 53 - 72% and specificities ranging from
70 - 84% (Lichtenstein, Bess, and Logan, 1988a).

Ventry and Weinstein (1982) found the HHIE to be a highly reliable measure of
hearing handicap, with reliability coefficients (alphas) ranging from 0.88 to 0.95. For
subjects 65 years old and older, the mean HHIE score was about 30, with a range between
0 and 98. This range indicates that the degree of hearing handicap cannot be measured
directly from audiometric data and that individuals react very differently to hearing
impairment. Ventry and Weinstein (1983) found that pure tone sensitivity measures
accounted for 3 1-3 8% of the variance in the total HHIE score, as well as in the emotional
and social-situational subscales. Speech recognition ability accounted for only 14-20% of
the variance in HHIE scores. Matthews, Lee, Mills, and Schum (1990) also found a low
correspondence between audiometric measures of hearing handicap and self-reported
hearing handicap as measured by the HHIE. The correlations between pure tone
thresholds and self-reported hearing handicap ranged from 0.39 to 0.63. Audiometric pure
tone thresholds were found to account for approximately 40% of the variance in HHIE

scores.

19

Ventry and Weinstein (1983) studied the relationship between audiometric data
(pure tone sensitivity and word recognition ability) and HHIE scores. They found that as
hearing loss increased, as measured by pure tone sensitivity, the HHIE score also
increased. Results, however, were extremely variable. Listeners who had pure tone
averages between 26 dB HL and 40 dB HL (a mild hearing loss) in the better car had the
most variable response on the HHIE. Of those listeners, 54% perceived little or no
handicap, 46% perceived some degree of hearing handicap, and 16% of that 46%
perceived significant hearing handicap. The degree of perceived handicap was defined by
the HHIE score. A score of 0—16% was considered no handicap, a score of 18-42% was
considered a mild to moderate handicap, and a score of greater than 42% was considered
a significant handicap. Pure tone averages greater than 40 dB HL were associated with a
sharp increase in HHIE scores. As the pure tone averages approached the normal range,
there was a sharp decrease in HHIE scores. There was an even weaker correlation
between word recognition scores and HHIE scores than was found between pure tone
averages and HHIE scores. These results are not unexpected given the poor reliability of
word recognition scores based on a tradeoff between measurement error and sample size,
as described by Thornton and Raffin (1978).

Weinstein, Spitzer, and Ventry (1986) fiirther assessed the test-retest reliability of
the HHIE. The original HHIE can be administered by two methods: either face-to-face or
via a pencil-and-paper version. The face-to-face administration involves the clinician’s

asking the HHI questions verbally in an interview situation. The pencil—and-paper version

20

is given to the patient for him or her to read and complete, either in the clinic or at home.
Both methods were found to have high test-retest reliability. For the face-to-face
administration approach, the reliability coefficients for the total score and the two
subscales ranged from 0.92 to 0.96. For the pencil-and-paper administration approach, the
reliability coefficients for the total score and the two subscales ranged fi'om 0.79 (just
below a value considered to be acceptable) to 0.84. The reliability of the total score for the
pencil-and-paper method was 0.84. The high test-retest reliability for both administration
approaches indicates that the self-assessment scale can be used to assess outcomes of aural
rehabilitation.

In clinical settings, the possibility exists that the clinician might verbally ask the
HHIE questions, with the subsequent HHIE being completed by the pencil-and-paper
administration approach. Newman and Weinstein (1989), therefore, studied the test-retest
reliability of the HHIE when these two administration methods were used in combination.
They found that the HHIE was highly reliable across administration approaches. The test-
retest reliability for the total score was 0.94, with the two subscales having reliability
coefficients of 0.91 (emotional) and 0.94 (social—situational). This finding supports the use
of the HHIE as an outcome measure, even when test and retest are administered by
different approaches.

Malinoff and Weinstein (1989) studied the use of the HHIE as a measure of
hearing aid benefit in the elderly population. They found a significant reduction in HHIE

scores after a three-week period of hearing aid use. Due to the high test-retest reliability of

21

the HHIE, the reduction in scores was indicative that the fitting of hearing aids had a
positive effect on the elderly population tested, and consequently on measured HHIE
scores.

Taylor (1993) also found that after three weeks of hearing aid use, patients’ HHIE
scores decreased significantly. Weinstein (1991) found a similar decrease in HHIE-S
scores after a three-week period. These studies suggest that the decrease in HHIE and
HHIE-S scores reflects a reduction in self-perceived hearing handicap, and that, given the
high test-retest reliability of these self-assessment scales, the perceived changes in hearing
handicap could be attributed to successful aural rehabilitation.

Bess (1995) reported that non-wearers of hearing aids had lower HHIE-S scores
than wearers of hearing aids, irrespective of degree of hearing loss. As the pure tone
average in the better ear increased, the HHIE-S score also increased. For all pure tone
average levels, however, the subjects who did not wear hearing aids consistently had
lower HHIE-S scores than subjects who chose to pursue amplification. Bess attributed this
finding to the fact that hearing-impaired persons who chose not to pursue amplification
typically had milder degrees of hearing impairment.

Newman, Jacobson, Hug, Weinstein, and Malinoff (1991) showed that an HHIE-S
score of 18 or more was notably related to successfiil hearing aid use. More specifically,
they found significant improvement in the perceived emotional and social-situational
effects of hearing impairment, based on change in HHIE-S scores, following short- and

long-term hearing aid use in clinical patients having pre-aided HHIE-S scores of 18 or

22

more. In the same study, Newman et al. also established a 95 percent confidence interval
of 9.3 for use in assessing a true change in perceived handicap between two
administrations of the HHIE-S. They recommended that the 9.3 value be rounded up to 10
for clinical purposes. A score obtained on the screening inventory after a hearing aid
fitting, therefore, would have to be lower by 10 or more than the pre-fitting score for the
fitting to be considered beneficial.

The HHIE and the HHIE-S have the potential for use as screening tools for
hearing loss in the elderly population (Lichtenstein, Bess and Logan, 1988b; Bess, 1995).
Mulrow, Tuley, and Aguiar (1990) evaluated the use of both the long and short versions
of two different self-assessment scales in hearing screening. One set of scales compared
was the Hearing Handicap Inventory for the Elderly (HHIE) and its companion short
version, the HHIE-S. The other was the Revised Quantified Denver Scale of
Communication Function (RQDS) and its short version, the RQDS -S. The authors found
the discriminative ability, or sensitivity, for correctly identifying hearing loss for the scales
to be as follows: HHIE - 78%, HHIE-S - 79%, RQDS - 73%, and RQDS-S - 74%. Using
the HHIE-S cutoff points for identifying people with hearing handicap and those without
hearing handicap, as defined by Ventry and Weinstein (1983), and comparing to
corresponding cutoff points on the RQDS-S, the HHIE-S identified significantly more true
positives than the RQDS-S. At lower cutoff points, the difference between the two scales
in identifying true positives was not statistically significant. The authors concluded that:

(1) the short versions of both scales were as clinically effective as the long-version

23

counterparts, and (2) the HHIE-S was a superior and versatile tool for use both in hearing
screening and as an outcome measure.

Lichtenstein, Bess, and Logan (1988a) also studied the performance of the HHIE-
S against differing definitions of hearing loss. Patients over the age of 65 years from
offices of four primary-care internists’ practices in the Nashville, Tennessee, area
participated in the study. The differing definitions of hearing loss included: Pure tone
Audiometry (1982 and 1983, criteria), Speech Frequency Pure Tone Average (SFPTA),
High Frequency Pure Tone Average (HFPTA), Speech Reception Threshold (SRT), and
Speech Recognition (Word Recognition Score). Different cutoff points were initially
chosen (2, 8, 16, and 24) to generate receiver-operating curves. The investigators found
that those subjects with HHIE-S scores of 0—8 had likelihood ratios between 0.36 and
0.55. Likelihood ratios less than 1.0 are associated with a reduced probability that hearing
loss is present. For the HHIE-S scores of 10-24 and 26-40, their data resulted in
likelihood ratios ranging from 1.46 - 2.71 and 4.16 - 23.19, respectively. Raising the
cutoff point increased the probability that individuals were categorized as hearing
impaired, regardless of the definition of hearing loss. The sensitivity and specificity were
specified for the various definitions of hearing loss. With the cutoff point set to 8, the
sensitivities for the HHIE-S for the differing definitions of hearing impairment were as
follows: Ventry and Weinstein pure tone criteria = 72%, SFPTA = 66%, HFPTA = 53%,
SRT = 62%, and Speech Recognition (Word Recognition Score) = 63%. The specificities

for the HHIE-S for the differing definitions of hearing impairment were as follows: Ventry

24

and Weinstein pure tone criteria = 77%, SFPTA = 79%, I-IFPTA = 84%, SRT = 72%, and
Speech Recognition = 72%. The authors concluded that the HHIE-S was a robust tool for
screening hearing loss in the elderly population.

In another study by Lichtenstein, Bess, and Logan (1988b), sensitivity and
specificity of the HHIE-S were analyzed for patients at two differing test locations: the
hearing center and the physician’s office. With a cutoff of 8 on the HHIE-S, the
sensitivities were 72% and 76%, and the specificities were 77% and 71%, for the hearing
center and the doctor’s office, respectively. When the cutofl’ was raised to 24 on the
HHIE-S, the sensitivities were 24% and 30% and the specificities were 98% and 96%, for
the respective locations. The best results with respect to identifying hearing loss were
found with the use of a Welch-Allyn Audioscope® in combination with the HHIE-S.l Test
accuracy increased to 83% with the use of both instruments, but each tool separately
(PIPHE-S and the Audioscope) was shown to provide a valid, reliable, and inexpensive
means for screening hearing loss in the elderly population.

Hearing Handicap Inventory for Adults

The Hearing Handicap Inventory for Adults (HHIA; Appendix C) was developed
in 1990 by Newman, Weinstein, Jacobson, and Hug for use with adults under the age of
65 years. This Hearing Handicap Inventory is similar to the HHIE. Three questions were
changed from the HHIE to account for the differing, primarily occupational, situations that

younger adults experience as compared to elderly adults (who are typically retired). Like

 

‘ This instrument is a portable otoscope capable of generating tones at 25 dB HL or 40 dB I-IL at 500 Hz,
1000 Hz, 2000 Hz, and 4000 Hz.

25

the HHIE, the HHIA has two subscales: social-situational reactions to a hearing loss and
emotional reactions to a hearing loss. As with the HHIE, 13 questions address the social-
situational reactions to a hearing loss and 12 questions address the emotional reactions to
a hearing loss, for a total of 25 questions. The HHIA is scored the same way as the HHIE.
The maximum possible score is 100, which represents the strongest perception of hearing
handicap. The points are totaled to produce an overall score, and subtotals can be
calculated for each of the two subscales.

The screening version of the HHIA, the HHIA-S (Appendix D), was developed by
Newman, Weinstein, Jacobson, and Hug (1991). It consists of 10 questions taken from the
original 25 questions of the HHIA. The HHIA-S contains 8 of the 10 HHIE-S questions;
thus only two questions differ between the HHIE-S and the HHIA-S. The maximum score
for the HHIA-S, as with the HHIE-S, is 40 points.

Newman et al. (1990) studied the psychometric adequacy and the audiometric
correlates of the HHIA. They found high internal consistency reliability (0.93 for the total
HHIA score) and a low standard error of measurement. The coefficient alpha for the
social-situational subscale was 0.85, and for the emotional subscale, 0.88. There was a
weak, but statistically significant, relationship between the HHIA scores and pure tone
sensitivity (based on SFPTA and I-IFPTA). Newman et al. found reliability coefficients to
range fiom 0.29 - 0.35. There was also a weak negative, yet statistically significant,
relationship between HHIA scores and Word Recognition Scores (-0.26 to -0.28).

Newman et al. concluded that because the pure tone sensitivity and the Word Recognition

26

Scores did not account for the large variation in the HHIA scores, it is important to
evaluate the patient’s own reaction to his or her hearing loss. The range of scores obtained
was 0-90 points, indicating a broad range of self-perceived hearing handicap. These
findings substantiated earlier findings, based on work with the HHIE (and reported
above), that audiometric measures alone are insuflicient to predict a patient’s reaction to a
hearing loss.

Newman et al. (1991) evaluated the test-retest reliability of the HHIA and the
HHIA-S. Their purpose was to evaluate the efficacy of using the HHIA as a measure of
aural rehabilitation outcomes, such as hearing aid benefit. The test-retest reliability of the
HHIA was high, with rs ranging from 0.93 to 0.97. The correlation coefficients for the
HHIA-S were also good, with a range from 0.82 to 0.93. The standard error of
measurement was low for both the HHIA and the HHIA-S. Newman et al. concluded that
the HHIA and the HHIA-S can be used as outcome measures due to the two self-
assessment scales’ high test-retest reliability.

O’Rouke, Britten, Hill, and Malson (1996) investigated the potential of the HHIA
as a hearing screening tool, in effect as a replacement for audiometric screening. They
found the internal consistency reliability (Chronbach’s alpha) to be high (0.91). The two
subscales’ internal consistency reliability was also high, 0.82 and 0.84 for the emotional
and social-situational subscales, respectively. Coefficient alphas for the HHIE-S and the
social-situational subscale were 0.85 and 0.84, respectively. Coefficient alpha, however,

for the emotional subscale was substantially lower—0.35. This latter finding contrasts with

27

that of earlier studies and no explanation for the low number was offered. The authors
found that subjects who failed the audiological screening scored significantly higher on the
HHIA and the HHIA-S than subjects who passed the audiological screening. They
expressed their belief that the HHIA and HHIA-S have the potential to be USCfiJl additions
to a hearing screening protocol for adults, and that the scales may be particularly useful
when ambient noise levels are too high for traditional pure tone audiometric screening.
Multimedia Hearing Handicap Inventory

The Multimedia Hearing Handicap Inventory (MHHI), developed by Punch and
Weinstein (1996), incorporates the HHIA-S and the HHIE-S into an interactive program
for use in a multimedia environment. Currently, a PC with a Windows 95/98 operating
system is required to run the program, which is commercially available. The Inventory is
stored on a CD-ROM, and runs fi'om the disk. For each social-situational question, there
is an option to view a video illustration of the type of situation to which the question
refers, and for each emotional question, the respondent has the option to have the question
rephrased. The MHHI can be taken with reference to either an unaided or aided listening
condition. At the time of program installation, selected information is stored on the system
hard drive, and key data produced by the program during its administration are stored on a
database that resides on the hard drive.

The MHHI is compartmentalized into a long program (LP) and a short program
(SP). The long program provides an educational context in which either the HHIA-S or

HHIE-S, depending on the respondent’s age range, is embedded. Basic information about

28

hearing loss and, for those who need it, a brief introduction to the computer, occur early in
the long program. Following the questionnaire, respondents can view a section on
Treatments for Hearing Impairment. Finally, an individualized Hearing Profile can be
printed out, which the respondent can take home.

By incorporating counseling information in the context of an educational
framework, and providing written recommendations for follow-up, the MHHI is consistent
with the Health Belief Model (Janz & Becker, 1984; Rosenstock, 1990). This model
suggests that patients are likely to comply with medical recommendations when they
consider themselves vulnerable to a particular condition, when the condition is perceived
as having serious medical or social consequences, when they perceive benefits from
seeking assistance, and when they perceive that few barriers to compliance exist. To
maximize the applicability of the Health Belief Model, the developers suggest that
respondents be encouraged to view the Multimedia HHI in its entirety (i.e., the long
program).

In the long program, the respondent can select a male or female talker as the
narrator. The text that the male or female talker narrates is also visible for the subject to
read at the same time through open captioning at the bottom of the computer monitor.
The long program takes about 15-20 minutes to complete. Patients answer each of the 10
questions in the questionnaire portion by clicking (with the mouse) on either Yes,
Sometimes, or No, which have respective weights of 4, 2, and 0. The computer

automatically calculates and stores the S, E, and total (T) scores. A Hearing Profile

29

containing the respondent’s total hearing handicap score and individualized follow-up
recommendations is printed out at the end of the questionnaire. The specific components
of the long program are described in Appendix E.

The short program of the MHHI consists of only the MHHI Questionnaire and the
Hearing Profile. It bypasses the introductory information and goes directly to the HHIA-S
or the HHIE-S, depending on the age selected. It utilizes the male voice as the default and,
like the long version, all text narrated by the male talker is available for the subject to read
at the bottom of the computer monitor. The short program takes approximately two
minutes to complete.

As shown in Table 2.1, the Hearing Profile consists of one of eight possible semi-
customized sets of recommendations, based on whether or not the given respondent has
previously completed the questionnaire, whether the hearing handicap score is 0-8 or 10-
40, and whether the condition referred to is unaided or aided. Components of the Hearing

Profile are detailed in Appendix F. Respondents who have taken the MHHI Questionnaire

Table 2.1: Hearing Profile contingencies.

 

 

Profile Score“ Database Aided
1 0-8 No Unaided
2 0-8 No Aided
3 0-8 Yes Unaided
4 0-8 Yes Aided
5 10-40 No Unaided
6 10-40 No Aided
7 10-40 Yes Unaided
8 10-40 Yes Aided

 

*There are no odd-numbered scores, such as 9, because response values are based on even
numbers (i.e., Yes = 4, Sometimes = 2, No = 0), and the total score is derived by summing
these values.

30

previously (with results stored on the database) are informed of their hearing handicap
score on the most recent test date, as well as their current score. Profiles 1 and 3 (Table
2.1) are ones in which unaided respondents who have low hearing handicap scores are
recommended to retake the questionnaire in one year, and to contact their audiologist or
physician if they feel they have a problem that afl‘ects their hearing. Profiles 2 and 4 are
ones in which aided respondents are told that their scores indicate that they are performing
well with their hearing aid(s). Respondents who receive Profiles 5 and 7 are considered
candidates for hearing or hearing aid evaluations, and are referred to an audiologist.
Respondents who receive Profiles 6 and 8 are informed that they are experiencing hearing
problems even with their hearing aids, and that they should consider repair or replacement
of their current aid(s), or additional interventions to supplement their hearing aids. For
individuals who have previously viewed either the short or long program, their Profiles
note their most recent score, and provide critical-difference information (in lay terms,
based on data from paper-and-pencil versions of the HHI) that will assist them in
determining whether the previous score is substantially different from the current score.
The design and substantive content of the eight possible Hearing Profiles are given in
Appendix G.

For each respondent, the MHHI stores 23 data items to the system’s hard drive on
a given test date: (1)-(10) weights representing answers to the 10 respective questionnaire
items, (Yes=4; Sometimes=2; No=0), (11) total B, the total emotional-item score, (12)

total S, the total social-situational-item score, (13) total, the total B + S score, used in

31

interpreting the printed Hearing Profile, (14) listening condition (Unaided; Aided), (15)
age (Below 40; 40 to 60; 61 to 80; Above 80), (16) respondent’s name, (17) respondent’s
ID number, (18) date, (19) time, (20) voice gender (Male; Female) preferred by the
respondent, (21) number of times ILLUSTRATE button was accessed, (22) number of
times REPI-{RASE button was accessed, and (23) whether the long program (LP) or short
program (SP) was accessed. The examiner’s name, title, address, and phone number are
stored on the hard drive, apart fiom the database information, and printed out as part of
the Hearing Profile for use as contact information for the respondent.

For retrieval purposes, the above data items are stored on the database as comma-
delimited text. This allows a simple means of importing the data to a database, statistical
package, spreadsheet, or word processing application of the user’s choice. Such
importation is essential to the reporting and analysis of aggregate or longitudinal data, but
is not necessary for routine clinical use. The database information was used as a primary
source of data for the analyses in this study.

This experiment sought to answer two primary questions concerning the use of the
Multimedia Hearing Handicap Inventory: (1) Does the MHHI, when administered on a
test-retest basis, provide a reliable measure of perceived hearing handicap in populations
of young and elderly adults? (2) What is (are) the 95 percent critical-difference value(s)
that may be used to evaluate the significance of differences in pre- and post-intervention

MHHI scores?

32

Several additional questions were of secondary interest in the experiment: (1) How
favorably do subjects react to the design and functional utility of the MHHI? (2) To what
extent are the educational and socioeconomic levels of the subjects, and their general
familiarity with computers and other technologies, associated with these reactions? (3)
Given the limited subject sample in this study, what evidence is available to suggest that
the MHHI provides a valid predictive measure for screening hearing loss in young and

elderly adults?

33

Chapter 3

Method

Overview

In two separate test sessions, adults with a range of hearing sensitivity were
administered a case history, one of three test-retest sequences of the Multimedia HHI
(MHHI), and a battery of routine audiologic measures. Case history information and
audiologic data were used to determine eligibility for participation in the study and for
inclusion in specific components of the data analyses. Analyses related to the assessment
of predictive validity were confined to 27 subjects, while the remaining analyses were
conducted on all 36 subjects.

Subjects

Subjects were recruited from the greater Lansing, Michigan, community. They
were recruited from the patient caseload of the Oyer Speech-Language-Hearing Clinic of
Michigan State University, the membership of the East Lansing Senior Center, and from
student and subject referrals.

The subjects were 18 men and 18 women, for a total of 36. Subjects were
randomly assigned to one of three subject groups, based on test-retest sequence: Long
Program/ Short Program (LP/ SP), Short Program/ Short Program (SP/SP), or Short
Program/Long Program (SP/LP). It was required, however, that six men and six women
be assigned to each of the three groups, for a total of 12 per group, and that an equal

number of adult and elderly adult subjects be administered the respective components of

34

the MHHI Questionnaire. For purposes of the study, adults were considered those aged
60 or younger, while elderly adults were considered those aged 61 years or older.2
Eighteen of the subjects qualified as elderly, with this subgroup consisting of 7 males and
11 females. Of the remaining 18 qualifying as non-elderly adults, 7 were females and 11
were males. A breakdown of subjects by gender and group is shown in Table 3.1.

Table 3.1: Distribution of male and female subjects in each test group, subdivided by
adult subjects fll/[HHI—A) or elderly adult subjects (Il/IHHI-E).

 

 

Group Number of Males Number of Females
LP/SP 6 6

SP/SP 6 6

SP/LP 6 6
MHHI-E 7 11
MHHI-A 11

Total 18 18

 

The 36 subjects ranged in age fiom 26-80 years. The mean ages for the three
experimental groups were 61.2 for the LP/SP group, 63.6 for the SP/SP group, and 61.6
for the SP/LP group. The age distributions for the various subject groups and subgroups
are given in Table 3.2. It is evident that the mean ages of adult (50.9 years) and elderly
adult subjects (73 .3 years) differed considerably and that the mean ages across the three
experimental groups and subgroups were highly similar.

The subjects’ hearing thresholds ranged from normal hearing to moderately severe hearing

impairment. Of the 36 subjects, 24 had normal hearing (three-fiequency PTA 525 dB HL),

 

2 This dichotomy is consistent with the design and function of the MHHI.

35

nine exhibited mild hearing impairment (>25 dB HL and 340 dB HL), two had moderate

losses (>40 dB HL and 355 dB HL), and one had a moderately severe hearing loss (>55

dB HL and 570 dB HL). All hearing losses were sensorineural, as determined by air- and

bone-conduction thresholds that were within no more than 10 dB of one another at each

audiometric frequency for a given ear. The mean hearing thresholds for the better ear

[based on the three-frequency pure tones averages or Speech Reception Thresholds

(SRT)] can be seen for the three experimental groups in Figure 3.1. The mean thresholds

for elderly subjects versus adult subjects are given in Figure 3.2, while the mean thresholds

for male subjects versus female subjects are shown in Figure 3.3.

Table 3. 2: Means and standard de viations for subjects, subdivided by inventory, gender,
experimental group, and age.

 

 

Group Number of Mean Age Standard

Subjects Age Rang Deviation
MHHI-E 18 73.3 17 (63 -80) 3.5
MHHI - A 18 50.9 33 (26 - 59) 9.6
LP / SP 12 61.2 37 (43 - 80) 14.0
SP / SP 12 63.6 42 (34 - 76) 12.3
SP/LP 12 61.6 51 (26-77) 14.7
Males 18 57.3 54 (26 - 80) 15.8
Females 18 66.6 24 (51 - 75) 8.7
LP / SP - Elderly 6 72.5 10 (70 - 80) 4.8
SP/ SP - Elderly 6 74.3 13 (63 - 76) 3.3
SP / LP - Elderly 6 73.0 6 (71 - 77) 2.2
LP / SP - Adult 6 49.8 16 (43 - 59) 10.0
SP / SP - Adult 6 52.8 24 (34 - 58) 6.6
SP / LP - Adult 6 50.2 33 (26 - 59) 12.7

 

36

Subjects with hearing loss and who wore hearing aids were included in the test-
retest reliability study. Nine of the thirty-six subjects wore at least one hearing aid.
Subjects who wore hearing aids were included in each of the three test groups. Three
subjects wore monaural hearing aids in the LP/ SP test condition, four subjects wore
binaural hearing aids in the SP/ SP test condition, and two subjects wore binaural hearing
aids in the SP/LP test condition.

Because the performance of the subjects on the MHHI may have been affected by
educational and socioeconomic factors, subjects were queried about education and (as a
proxy for socioeconomic status) annual income. The subjects’ educational levels are
shown in Table 3.3. The educational levels of the subjects varied from not completing high
school to completing professional and doctoral degrees. While 2.8% had not completed
high school, 30.6% of the subjects had at least one year of college, 41.7% had bachelor’s
degrees, 13.9% had master’s degrees, and 11.1% had either professional or doctoral
degrees. The relatively high levels of education in the overall sample reflect the fact that
most of the subjects were recruited within the community that included or surrounded
Michigan State University.

Subjects’ mean annual income levels are given in Table 3.4. The modal income
(30.6%) was $30,000-$50,000. For 13.9% of the subjects, annual incomes of $30,000 or
under were reported, while 22.2% and 25%, respectively, reported incomes of $50,000-

$75,000 and $75,000 or more. Incomes were not reported by 8.3% of the subjects.

37

Frequency (Hz)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

250 500 1000 2000 4000 8000
~10
0
10 +I.P/SP
201 \ +sp/sp
+SP/LP
30
53 4° \
E 50 \
.3 N
E." 6°
3-
3 70
a:
so
90
1(1)
110
120

Figure 3.1: Mean air-conduction audiometric thresholds for the better ears of the
experimental groups. Each group included 12 subjects, six of whom were adults and six
of whom were elderly adults, classified as described in the text.

38

Hearing Level (dB)

Frequency (HI)

8000

 

 

 

 

 

 

 

 

 

 

 

 

 

—o—Elderly
— - o~— (lower)-1 SD
——0--(upper)+l SD
+Adults
H-.. (lower)-l SD
---u--- (upper)+1 SD

 

 

 

 

 

 

 

250 500 2000 4000
-10 4 1 i
0 i """"""""""" ‘-.
'fi ~
10 r- ‘ .......
"fi
\.\ "-, \k ‘\ \
- n". ‘\L
40 ‘-\ u i
.\- ".n '\l_\
‘ . \t
50 i
\. '.
‘~ \
60 a ‘
\. ‘-
‘D.
70 ‘\.
‘\
r
MD
“0
120

 

 

 

 

 

 

 

Figure 3.2: Mean air-conduction audiometric thresholds for the better ears of adult and
elderly adult subjects. Each group included 18 subjects.

39

 

Frequency (Hz)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

250 500 1000 2000 4000 3000
-10 g
0.1 __________ - #__,_A?
10 _ _ g
a.-___
20 a .-n‘. R kfl~—-_—fi.§
30‘ ' i. (Male
5 L\‘.».\“M> ‘.\.\~ \ 1’ —_....‘_(10wer)-1 SD
3 ' : _ - -I- . . (upper) +1 SD
0 3‘ ‘ +Female
A
E” 60 .. s. __.C_ (lower)-1 SD
.5 __ 4..- (upper)+1 SD
5 70 in g
"‘8
100
110
120

 

 

 

 

 

 

 

Figure 3. 3: Mean air-conduction audiometric thresholds for the better ears of male and
female subjects. Each group included 18 subjects.

40

Table 3. 3: Subjects’ educational levels.

 

 

Educational Level Number Percentage
Did not complete High School 1 2.8 %
One or more years of college 11 30.6 %
Bachelor’s Degree 15 41.7 %
Master’s Degree 5 13.9 %
Professional Degree or 11.1 %
Doctoral Degree 4
Total 36 100.1 %

 

Table 3. 4: Subjects’ annual net incomes.

 

 

Income Number Percentage
$0-$15,000 2 5.6%
$15, 000 - $ 30,000 3 8.3 %
$ 30,000 - $ 50,000 11 30.6 %
$ 50,000 - $ 75,000 8 22.2 %
$ 75,000 or more 9 25.0 %
No Response 3 8.3 %
Total 36 100.0 %

 

T est-Retest Sequences
Recall that the three experimental groups were:
1. Test - Long Program / Retest - Short Program (LP/SP)
2. Test - Short Program / Retest - Short Program (SP/SP)
3. Test - Short Program / Retest - Long Program (SP/LP)
Any of these test sequences is likely to occur in a clinical setting. Although the
developers of the MHHI (Punch and Weinstein, 1996) regard the LP/SP condition as the

most preferred, the other two sequences are included because they are very likely

possibilities in some clinical settings. For example, the SP condition may be administered

41

as a screening measure of hearing handicap within or outside a hearing clinic, and the LP
condition administered during an audiologic follow-up. To save time, some examiners
might employ the SP/ SP sequence. Because an LP/LP sequence is less likely to occur
clinically, particularly within the three-week test-retest interval used in this investigation, it
was not included as an experimental sequence.
Audiologic Evaluation

All audiometric testing was conducted bilaterally for each potential subject at the
Oyer Speech-Language-Hearing Clinic, Michigan State University, in one of the Clinic’s
audiometric sound rooms. Otoscopy was first performed on each subject. Pure tone and
speech audiometric testing was then performed using the GSI-16 audiometer equipped
with Telephonics TDH-39 headphones and a Radioear B-71 bone-conduction receiver.
SRTs were obtained utilizing CID W-l spondee words (I-Iirsh, Davis, Silverrnan,
Reynolds, Eldert, and Benson, 1952) and word recognition scores were obtained using
List l-A and l-B of the NU-6 monosyllabic words (Tillman and Carhart, 1966). Audio
CD recordings (Auditech of St. Louis) of these speech audiometric materials were used.
Tympanograms were obtained with the GSI-33 immittance bridge, which was located in a
quiet area outside the audiometric sound room. Electroacoustic analysis of any hearing
aids worn by the subjects was performed using the Fonix 6500-C Hearing Aid Test
System. Calibration of audiometric equipment was performed immediately prior to the
experiment, and biological calibration was completed periodically throughout the

experiment. In addition, a stafi‘ technologist maintained the calibration of all audiometric

42

equipment used in the study as part of a regular maintenance schedule observed in the
Oyer Clinic.

A multimedia-equipped PC, running at 200 MHz, with Sound Force 660 speakers
and an associated inkjet printer, was used for all administrations of the MHHI. All MHHI
administrations were completed in a sound-treated room designed to minimize external
sound interference and internal sound reflections. The ambient noise in this room was
typically around 43 dBA and 67 dBC, as measured by a Larson-Davis, Model 8008,
sound level meter.

Interview Materials

A case history developed for the study was completed by all subjects prior to the
first test session to assure their eligibility as participants. The case history questions were
used to assess hearing health status, to determine possible causes of any existing hearing
loss, and to establish a baseline against which to determine any change in hearing status
between the first and second sessions. The case history consisted of the following
questions (see Appendix H for case history form):

1. Do you think you have a hearing loss?

2. If so, was it gradual or sudden?

3. Do you notice any tinnitus (ringing or other sounds) in your ears?

4. Do you have a history of exposure to loud noises?

5. Do you have a history of ear infections?

6. Do you experience any dizziness or vertigo?

43

7.

8.

9.

What medications are you currently taking?
What medications have you taken in the past for a prolonged period of time
(one year or more)?

Have you noticed any fluctuation in your hearing in the past six months?

10. Do you currently wear hearing aids?

11. If so, how often and for how long do you wear the hearing aids?

A different set of case history questions was asked during the second session to

assure consistency in hearing health during the test-retest interval. This was considered

necessary to rule out extraneous factors (i.e., those outside the test measures themselves)

that may have confounded results and interpretation of the test-retest reliability data. The

following case history information was sought at the beginning of the second visit (see

Appendix I for case history form):

1.

2.

Are you aware of a change in your hearing ability since the last test session?
Have you had a head injury since the last session?

Do you notice any tinnitus (ringing or other sounds) in your ears?

Has there been any change in any medications you are taking since the last
session?

Do you experience any dizziness or vertigo?

Have you been exposed to loud noise since the last session?

If so, did you notice any tinnitus after the noise exposure?

8.

Have you noticed any fluctuation in your hearing since the last session?

9. Have you acquired a new hearing aid, or aids, since the last session?

10. If so, how often and for how long do you wear it/them?

11. Has there been any change in the performance of your hearing aid(s) since the

last session?

An exit questionnaire was administered at the end of the second session. Questions

were answered on a 5-point Likert scale (1 - 5, where 1 = strongly disagree and 5 =

strongly agree) and used to assess subject perceptions of the Multimedia HHI. The

following is a list of questions used in the two exit questionnaires. (The actual

questionnaires, as designed for two subgroups of subjects— those who performed either

the LP/ SP or SP/LP sequence or those who performed the SP/ SP sequence,

respectively—are shown in Appendices J and K.) Questions included in the Short Program

Exit Questionnaire were:

1.

2.

The Multimedia Hearing Handicap Inventory program was easy to use.
The voice was easy to hear.

The voice was easy to understand.

The text was easy to read.

The Hearing Profile given to me at the end of the program was easy to
understand.

I will follow the suggestions given to me in the Hearing Profile.

45

Questions included in the Long Program Exit Questionnaire were:

1.

2.

10.

ll.

12.

The Multimedia Hearing Handicap Inventory program was easy to use.

I found the section on use of the computer to be helpful.

. I found the rephrasing of the questions helpfirl.

I found the illustrations of the questions helpful.

. I learned some usefirl information about hearing loss from the program.

The voice was easy to hear.

The voice was easy to understand.

The text was easy to read.

I could easily follow the directions on how to use the program.

I learned some usefirl information about treatments for hearing loss.
The Hearing Profile given to me at the end of the program was easy to
understand.

I will follow the suggestions given to me in the Hearing Profile.

Three additional questions were asked of each subject at the end of the exit

interview. They were asked to indicate their salary range and educational level, and to rate

the extent of their level of comfort with technologies including typewriters, calculators,

adding machines, and computers.

46

Procedures

Approval for the use of human subjects in this study was sought and approved by
Michigan State University’s Institutional Review Board (IRB). Prior to the first test
session, potential subjects were either mailed or given a case history form (paper-and-
pencil format), which they completed at home and mailed back to the examiner. Afier
receipt of the case history, the subjects were contacted by telephone. An effort was made
to clarify all Yes responses on the case history form and to interpret the responses in light
of their implications for participation in the study. The experimenter then made a decision
regarding the eligibility of the individual to participate, and each participating subject was
asked to sign an Informed Consent Form. Subjects were not paid for their participation,
but were administered all audiologic tests free of charge and offered individual counseling
following the completion of all experimental procedures.

Each subject was required to participate in two different test sessions (test and
retest) separated by approximately a three-week interval. All subjects completed the retest
exactly three weeks apart, with the exception of two subjects whose retest sessions were
held three and one-half weeks after the first.

Both the first and the second sessions entailed the same test protocol: case history,
MHHI, and audiological evaluation. This order was fixed for two, somewhat related,
reasons: (1) to conform to what might be considered a typical clinical protocol, in which
the MHHI is administered prior to the hearing evaluation to serve as the basis for

audiologic referral, and (2) to preclude contamination of the MMHI hearing handicap

47

score by perceptual biases that could potentially be introduced during the audiologic
battery.

Table 3.5 indicates those conditions that signaled ineligibility of subjects to
participate in either the reliability or the validity components of the study, based on the
first case history. Students and professionals in audiology or speech-language pathology
were excluded from all aspects of the study. Individuals who indicated the presence of a
middle ear infection or sudden hearing loss within the past three months were excluded
from both the validation and the reliability components, as were any persons for whom a
fluctuating hearing loss was reported or documented. Subjects who currently wore hearing
aids were administered all experimental measures, but only their data bearing on the test-
retest reliability study were analyzed. Thirty-six subjects qualified for the reliability
analysis, while 27 qualified for the validity analysis.

For subjects considered eligible for one or both analysis components, an appointment was
made to complete the MHHI and an audiological evaluation. Each participating subject
first completed the Multimedia HHI, with hearing aid users being instructed to answer as
if they were wearing their hearing aids. A routine audiological evaluation followed,
consisting of otoscopy, tympanometry, air- and bone-conduction audiometric thresholds,
speech recognition thresholds (ASHA method, Asha, 1988) and word recognition testing.
Test frequencies during pure tone audiometry included all audiometric fiequencies
between 250 Hz - 8000 Hz for air-conduction testing, and 250 Hz - 4000 Hz for bone-

conduction testing. After audiologic testing, a listening check and electroacoustic analysis

48

were performed on all hearing aids worn by subjects to determine whether the devices
were working properly and appropriate for their current hearing losses. At the end of the
first session, an appointment was made for the second session. The second visit started
with a paper-and-pencil case history, completed by the subject. If the subject indicated any
of the following conditions since the first evaluation, the subject was excluded from the
test-retest reliability study: a significant hearing change, a head injury, tinnitus that was not
present on the first case history, new hearing aids, a current hearing aid that was not
functioning properly, or new medications that were potentially ototoxic. The case history
was followed by the MHHI. An abbreviated audiometric evaluation, consisting of air-
conduction thresholds and tympanometry, was then administered. For hearing aid users,
the examiner performed a listening check and electroacoustic analysis of their hearing aids.
The subjects completed a paper-and-pencil exit questionnaire. Lastly, the examiner
answered any questions the subjects had about the purpose of the study, and counseled
them with respect to their audiological findings and clinical follow-up recommendations.4
The printed Hearing Profiles from the MHHI test and retest sessions were made available

to the subjects at the end of the experiment.

 

4 All experimental procedures for patients of the Oyer Speech-Language-Hearing Clinic were
administered in the context of any ongoing hearing and hearing aid evaluation appointments. Any new
hearing aid fittings, however, were delayed until afier the completion of all experimental prowdures.

49

Table 3.5: Bases for eliminating subjects fiom test-retest reliability analysis and validity
analyses, based on first case history.

 

 

 

 

 

 

 

 

 

 

Current or recent rmddle ear Current or recent rmddle ear
infectionsLA/ithin last 3 months) infections (within last 3 months)
Sudden hearing loss (within last 3 Sudden hearing loss (within last 3
months) months)
Reported or documented fluctuating Reported or documented fluctuating
hearing loss hearing loss

Current hearing aid users3
Students or professionals in Students or professionals in
Audiology or Speech-Language Audiology or Speech-Language
Pathology Pathology

 

Some subjects were excluded fiom the reliability analysis despite their completion
of both test sessions. Such exclusion arose from factors related to information derived
from their second case history or from results of the two hearing evaluations or two
analyses of hearing aid performance. The bases for excluding subjects fiom the test-retest
reliability study are shown in Table 3.6.

Significant health changes were characterized by any of the following conditions:

1. Subjects with a cold and exhibiting Type B or Type C tympanograms

 

3 The experimental question with respect to validity was whether the MHHI, a measure of hearing
handicap, is capable of identifying hearing impairment. Subjects who wear hearing aids may be presumed
to have a hearing impairment and to admit it readily, particularly if asked to respond as if they were
unaided. To obtain those data for the validity analysis, the examiner would have had to instruct them to
refer to the unaided listening condition. That condition may be far removed from their immediate
everyday (aided) experience and they may have had difficulty in reporting their perceptions based on
unaided listening. In the reliability study, the examiner would have had to ask them to refer to the aided
condition on the MHHI. It was decided, therefore, not to have hearing aid wearers participate in the
validity study.

50

2. Subjects with a head injury since the first session and experiencing any of the
following: tinnitus, dizziness, or vertigo

3. Subjects who were exposed to loud noise with post-exposure tinnitus

4. Subjects who noticed a fluctuating hearing loss

5. Subjects who had started taking potentially ototoxic medication(s) since first
session

6. Subjects who perceived a change in their hearing status

Table 3. 6: Bases for eliminating subjects fiom test-retest reliability analysis, based on
second case history or audiometric data.

 

Ineligihility Based on Case History Ineligibility Based on Audiometric Data

 

Documented or perceived fluctuating Non-functioning or malftmctioning hearing

hearing loss aids of current hearing aid users, or hearing
aids whose functioning has changed since
the first test session [defined by

electroacoustic measurements: HFA-FOG,
HFA SSPL90, or Equivalent Input Noise

 

(BIN) > 5 dB between sessionfl
Significant change, or potential change, in Audiometric thresholds that differ between
hearing health status since first session sessions by 10 dB HL or more at two

fiequencies, or 15 dB HL at one fiequency

 

 

Malfimctioning hearing aid, or acquisition
of new hearing aid(s) since first session

 

 

The case history information, MHHI data, and audiometric findings from the first
session were used for the validity analyses. For these analyses, an audiological pass was
variously defined by the following criteria: Speech Frequency Pure Tone Average

(SFPTA) < 25 dB HL, Speech Frequency Pure Tone Average (SFPTA) < 20 dB HL,

51

 

Speech Reception Threshold (SRT) < 25 dB HL, Speech Reception Threshold (SRT) <
20 dB HL, High Frequency Pure Tone Average (HFPTA) < 25 dB HL, High Frequency
Pure Tone Average (HFPTA) < 20 dB HL, the Word Recognition Score (WRS) Z 90 %,
or the Ventry and Weinstein (1982, 1983) criteria. Ventry and Weinstein considered a
subject as hearing impaired if a subject had audiometric thresholds at 1000 or 2000 Hz 2
40 dB HL in both ears and/or a subject had a hearing loss at 1000 and 2000 Hz 2 40 dB

HL in one ear.

52

Chapter 4

Results and Discussion

Overview

In this chapter, results of the following analyses are reported and discussed: (1) a
multivariate analysis of audiometric threshold data, (2) a descriptive analysis of MHHI
scores, (3) analyses of MHHI’s test-retest reliability and internal consistency reliability, (4)
an analysis of critical-difference scores on the MHHI, (S) preliminary analyses of the
MHHI’s predictive validity, (6) analyses of the clinical utility and ease of use of the
MHHI, (7) an analysis of the exit-interview questionnaire, and (8) an analysis of the
relationship between ease of use of the MHHI and educational and income levels.

The analyses revealed the MHHI to have high test—retest reliability and internal
consistency. A 95 percent critical-difference value of 10 was established as suflicient to
reveal statistically significant differences in MHHI scores obtained across different
administrations. The relatively low number of subjects, the low number of subjects with
hearing loss, and the limited overall degree of hearing impairment exhibited, provided an
insufficient basis for conclusions regarding the MHHI’s predictive validity. Nonetheless,
certain aspects of the analyses were encouraging. Subjects regarded themselves as
generally familiar with selected technologies and responded favorably to the design and

functional characteristics of the MHHI. No substantial relationship was revealed between

53

subjects’ perceptions of the MHHI and either their socioeconomic status or their level of
comfort with technology. Finally, indications for future research are discussed.
Hearing Sensitivity Across Subject Groups

A General Linear Model (GLM) for repeated measures was used to determine
significance of differences across subject groups. The subjects’ thresholds in the three
experimental groups (LP/SP, SP/SP, and SP/LP), shown in Figure 3.1, were analyzed to
verify comparability of groups with respect to subjects’ mean audiometric sensitivity. No
significance differences were found in audiometric thresholds across the three
experimental groups (p <0.05). This outcome provides assurance that any differences that
may occur among these groups in later analyses cannot be attributed to differences in
hearing sensitivity among them.

When the GLM analysis was applied to a comparison of adult versus elderly adult
subjects (Figure 3.2), a significant difference (p > 0.05) in audiometric thresholds was
observed. Elderly adults exhibited poorer hearing thresholds at 2000, 4000, and 8000 Hz.
Although this finding suggests the need for caution in interpreting the data, such
differences between results for these two groups are not surprising, given the well-known
higher prevalence of hearing loss in the elderly population.

Audiometric thresholds for male versus female subjects were subjected to a similar
analysis. As demonstrated in Figure 3.3, fenmles tended to have slightly poorer mean
hearing thresholds than male subjects across a broad range of fiequencies. This can

probably be explained by the fact that female subjects had a higher mean age than the male

54

subjects (Table 3.2). Results of the GLM analysis, however, revealed the difl’erences not
to be statistically significant except at 500 Hz. It is the author’s view that such differences
are not likely to account for any differences between the males’ and females’ responses to
the MHHI.
Descriptive Analyses of MHHI

MHHI scores will first be reported by various subgroups. Descriptive analyses
include the means, standard deviations, and 95% confidence intervals of the test and retest
scores for the overall MHHI, MHHI-E, and MHHI-A (Table 4.1), as well as for the three
experimental groups LP/SP, SP/SP, and SP/LP (Table 4.2). Scores reported in Table 4.1
and Table 4.2 cover the overall subject sample, and, therefore, include the scores of
subjects without regard to their degree of hearing impairment. The mean MHHI scores
ranged fiom 13.33 (MHHI-A retest) to 15.83 (LP/SP test). Mean results for the various
subject subgroups were in excellent agreement from test to retest.
Test —Retest Reliability
Test-retest reliability refers to the extent to which a repeated test will yield the same score
as the original test. The test-retest reliability of the MHHI was assessed using Pearson
product-moment correlation coefficients (rs). Correlations were calculated for the overall
MHHI, the MHHI-E, the MHHI-A (Table 4.3), the three experimental groups LP/ SP,
SP/SP, and SP/LP (Table 4.4), males and females (Table 4.5), and subgroups by age and
gender (Table 4.6). In all cases, the reliability coefficients were calculated for the total

scores and scores for each of the two subscales (emotional and social-situational).

55

Table 4.1: Means, standard deviations, and 95% confidence intervals for test and retest
conditions for MHHI, MHHI-E, and MHHI—A. (standard deviations are in parenthesis;
95 % confidence intervals are in brackets).

 

 

Group Test Retest
MHHI Total = 14.4 Total = 12.17
(9.00) (9.5)
[11.4 -17.4] [10.9 -17.4]
Emotional = 6.0 Emotioml = 5.4
(4.7) (4.9)
[4.4 - 7.6] [3.8 - 7.1]
Social = 8.4 Social = 8.7
(5.2) (5.3)
[6.6 - 10.1] [6.9 - 10.5]
MHHI-E Total = 15.0 Total = 15.0
(8.1) (8.0)
[11.0 -19.0] [11.1- 19.0)
Emotional = 6.0 Emotional = 5.7
(3.9) (4.5)
[4.1 - 7.9] [3.5 - 7.9]
Social = 9.0 Social = 9.3
(4.8) (4.4)
[6.6 - 11.4] [7.2 - 11.5]
MHHI-A Total = 13.8 Total = 13.3
(10.0) (11.1)
[8.8 - 18.8] [7.8 - 18.8]
Emotional = 6.0 Emotional = 5.2
(5.4) (5.4)
[3.3 - 8.7] [2.6 - 7.9]
Social = 7.8 Social = 8.1
(5.7) (6.1)
[5.0 - 10.6] [5.1 - 11.2]

 

56

Table 4. 2: Means, standard deviations, and 95% confidence intervals for the three

experimental groups. (standard deviations are in parentheses; 95 0 o confidence intervals

are in brackets).

 

 

Group Test Retest
LP/SP Total = 15.8 Total = 14.8
(9.8) (9.6)
[9.6 - 22.1] [8.7 - 21.0]
Emotional = 6.8 Emotional = 5.5
(4.4) (4.6)
[4.1 - 9.6] [2.6 - 8.4]
Social = 9.0 Social = 9.3
(6.4) (5.5)
[5.0 -13.0] [5.9 -12.8]
SP/SP Total = 13.5 Total = 13.7
(9.0) (9.3)
[7.8 - 19.2] [7.7 - 19.6]
Emotional = 5.7 Emotional = 5.3
(5.2) (5.4)
[2.4 - 9.0] [1.9 - 8.7]
Social = 7.8 Social = 8.3
(4.8) (5.0)
[4.8 - 10.9] [5.2 -11.5]
SP/LP Total = 13.8 Total = 14.0
(8.8) (10.4)
[8.3 - 19.4] [7.4 - 20.6]
Emotional = 5.5 Emotional = 5.5
(4.7) (5.1)
[2.5 - 8.5] [2.3 - 8.7]
Social = 8.3 Social = 8.5
(4.7) (5.8)
[5.4 - 11.3] [4.8 - 12.2]

 

57

Pearson rs for the total scores and emotional and social-situational subscale scores
of the MHHI showed test and retest scores to be highly correlated, being at least 0.86.
Generally, high correlations were also observed for test-retest scores on the MHHI-E and
MHHI-A, for emotional, social, and total scores. Each experimental group (LP/ SP,
SP/SP, and SP/LP) also showed high correlations for total and both subscales. Overall, all
rs were high and statistically significant (p <0.01), except for the scores of the elderly
adult male group. All Pearson rs were greater than 0.7, thereby accounting for 50% or
more of the variance, with the exception of elderly adult male subjects, whose respective
Pearson rs for test-retest reliability for the emotional subscale and total score were 0.43
and .49. These relatively low correlations might be explained by a combination of
relatively few subjects (7) and age, but appear not to be explained by either factor alone,
as correlations were notably higher for the group of 7 adult females and 11 elderly
females. Recall that the MHHI-E and MHHI-A questionnaires differ by only two
questions. It seems reasonable to expect any differences in performance on these two
versions of the questionnaire, therefore, to be attributed more to differences in age of the
subjects than to differences in the inventories themselves. The overall conclusion fiom
Tables 4.3-4.6 is that test-retest reliability was consistently high for all subject

classifications except for the fairly small subgroup of elderly adult males.

58

I!

.--II

,u-L

Table 4. 3: Pearson product-moment correlations for MHHI, MHHI-E, and MHHI-A,
based on emotional score, social score, and total score.

 

 

Group Emotional Score Social Score Total Score
MHHI (n = 36) .86* .86* .91*
MHHI- E (n = 18) .73* .87* 86*
MHHI - A (n =18) .93* 86* .94*

 

*Significant at 0. 01 level, 2-tailed

Table 4. 4: Pearson product-moment correlations for three experimental groups, based on
emotional score, social score, and total score.

 

 

Group Emotional Score Social Score Total Score
LP-SP (n = 12) .83* .87* .90*
SP—SP (n = 12) .84* .84* .93*
SP-LP (n = 12) .91* .91* 92*

 

*Significant at 0. 01 level, 2-tailed

Table 4. 5: Pearson product-moment correlations for male and female subjects, based on
emotional score, social score, and total score.

 

 

Group Emotional Score Social Score Total Score
Males (n = 18) 87* .84* 89*
Females (n= 18) .86* .88* .93*

 

*Significant at 0.01 level, 2-tailed

The MHHI Pearson rs are comparable to previous studies of other versions of the
Hearing Handicap Inventories. Ventry and Weinstein (1982) found reliability coefficients
ranging fiom 0.88 to 0.95 for the HHIE. Weinstein, Spitzer, and Ventry (1986) showed
reliability coefficients for the HHE to range from 0.92 to 0.96 and 0.79 to 0.84 for the

emotional and social subscales, respectively. Newman, Weinstein, Jacobson, and Hug

59

All

>-
._l-

at:

0:4
‘br
\

[11h

(1991) found Pearson rs ranging from 0.93 to 0.97 for the HHIA, and 0.82 to 0.93 for the
HHIA-S. With a combined administration approach of verbally asking the HHIE
questions and a pencil-and-paper completion, Newman and Weinstein (1989) again found
the reliability to be high (total score = 0.94, emotional subscale = 0.91, and the social-

situational subscale = 0.94).

Table 4. 6. Pearson product-moment correlations for subjects subdivided by age group
and gender, based on emotional score, social score, and total score.

 

 

Group Emotional Score Social Score Total Score
Adult Males 99* .87* .96*
(n = 11)
Adult Females .89* .87* .94*
(n = 7)
Elderly Males .43 .71 .49
(n = 7)
Elderly Females .87* .89* .94*
(n=1 1)

 

*Significant at 0.01 level, 2-tailed

The MHHI Questionnaires are highly reliable. Except for the limited case of
elderly adult males, subjects tended to perform very similarly on test and retest
administrations. Given no aural rehabilitation or intervention nor any change in their
audiometric data between different administrations of the MHHI, subjects’ scores can
generally be assumed to reflect stabilized perceptions of their hearing handicap.
Internal Consistency Reliability .

The internal consistency reliability of the MHHI was assessed using Cronbach’s

alpha (Cronbach, 1951; Carmines and Zeller, 1979). This measure provides a conservative

60

estimate of the average value of the internal consistency of all possible combinations of
items comprising half-tests (Iversen and Norpoth, 1976). Cronbach’s alpha was calculated
for the various subgroups of interest, covering test and retest scores and scores for the
two subscales. The subgroups analyzed include adults and elderly adults, the experimental
test groups (LP/SP, SP/SP, and SP/LP), adults and elderly adults within experimental
groups, the MHHI-E, MHHI-A, and the overall MHHI.

Results are shown in Table 4.7 - Table 4.10. Total score alphas ranged from 0.79
(adults administered SP/SP test condition) to 0.96 (adults administered the SP/LP retest
condition). Subscale alpha values ranged from 0.25 (emotional subscale for elderly adult
subjects in the test SP/SP condition) to 0.95 (social subscale for adults in the retest SP/LP
condition).

Results of the internal consistency reliability analysis for the MHHI are comparable
to the results of O’Rouke, Britten, Hill, and Malson (1996) for the HHIA-S. O’Rouke et
al. found the total score alpha to be high (0.91), with alpha for the emotional and social
subscales being 0.82 and 0.84, respectively. The MHHI-A subscale values (see Table 4.7)
were similarly high, ranging from 0.81 (social subscale) to 0.88 (emotional subscale). The
lowest alpha occurred for the emotional subscale for the MHHI-E (0.61). Interestingly, in
the study of Rouke et al., the emotional subscale also showed a substantially lower
Cronbach alpha (0.35). Nonetheless, the relatively low number of subjects included in the

present analyses may have been partially responsible for suppressing some of these internal

61

T.
1 Llf

ml

consistency reliability values. O’Rouke et al. had 96 subjects in their study, whereas the

number of subjects ranged from 6 to 36 for the various groups analyzed in this study.

Table 4. 7: Cronbach ’s alpha for the MHHI by test and retest administrations and major
subject subgroup.

 

 

Group Cronbach Alpha - Test Cronbach Alpha - Retest
MHHI Total = .84 Total = .89
(n = 36) Emotional = .75 Emotional = .85
Social = .73 Social = .81
MHHI-E Total = .82 Total = .85
(n = 18) Emotional = .61 Emotional = .77
Social = .75 Social = .77
MHHI-A Total = .87 Total = .93
(n =18) Emotional = .82 Emotional = .88
Social = .81 Social = .86
LP/SP Total = .84 Total = .89
(n = 12) Emotional = .64 Emotional = .77
Social = .84 Social = .82
SP/SP Total = .85 Total = .89
(n=12) Emotional = .88 Emotional = .87
Social = .73 Social = .72
SP/LP Total = .86 Total = .94
(n = 12) Emotional = .80 Emotional = .85
Social = .84 Social = .86

 

62

ll

Table 4. 8: Cronbach ’s alpha for the three experimental groups, subdivided by test and
retest administrations, adult and elderly adult subjects, and inventory subscales.

 

 

Group Cronbach Alpha - Test Cronbach Alpha - Retest
LP/SP - MHI-H-E Total = .84 Total = .73
(n = 6) Emotional = .62 Emotional = .65
Social = .52 Social = .83
SP/SP - MHHI-E Total = .89 Total = .86
(n = 6) Emotional = .74 Emotional = .84
Social = .81 Social = .60
SP/LP - MHHI-E Total = .75 Total = .84
(n = 6) Emotional = .25 Emotional = .71
Social = .81 Social = .79
LP/ SP - MHHI-A Total = .81 Total = .92
(n = 6) Emotional = .58 Emotional = .81
Social = .93 Social = .85
SP/SP - MHHI-A Total = .79 Total = .93
(n = 6) Emotional = .95 Emotional = .95
Social = .53 Social = .81
SP/LP - MHHI-A Total = .93 Total = .96
(n = 6) Emotional = .85 Emotional = .92
Social = .85 Social = .95

 

63

Table 4. 9: Cronbach ’3 alpha for the two versions of the MHHI (short and long
programs), for test and retest administrations in diflerent experimental groups.

 

 

Program Cronbach Alpha - Cronbach Alpha -
Test Data Retest Data
SP SP-SP (n = 12) LP- SP (n = 12)
Total = .85 Total = .89
Emotional = .88 Emotional = .77
Social = .73 Social = .82
SP-LP (n = 12) SP-SP (n = 12)
Total = .86 Total = .89
Emotional = .84 Emotional = .87
Social = .80 Social = .72
LP LP-SP (n = 12) SP - LP (n = 12)

Total = .84
Emotional = .64
Social = .84

Total = .94
Emotional = .85
Social = .86

 

Table 4.10: Cronbach ’s alpha for the MHHI-E and MHHI-A and the short and long

 

 

programs of the MHHI.
Group Cronbach Alpha - Cronbach Alpha -
Test Data Retest Data
MHHI-E - LP LP/SP MHHI-E (n = 6) SP/LP MHHI- E (n = 6)
Total = .84 Total = .84
Emotional = .62 Emotional = .71
Social = .52 Social = .79
MHHI-E - SP SP/SP MHHI-E (n = 6) SP/SP MHHI-E (n = 6)
Total = .89 Total = .86
Emotional = .74 Emotional = .84
Social = .81 Social = .60
SP/LP MHHI-E (n = 6) LP/SP MHHI-E (n = 6)
Total = .75 Total = .73
Emotional = .25 Emotional = .65
Social = .81 Social = .83
MHHI-A - LP LP/SP MHHI- A (n = 6) SP/LP MHHI-A (n = 6)
Total = .81 Total = .96
Emotional = .58 Emotional = .92
Social = .93 Social = .95
MHHI-A - SP SP/SP MHHI-A (n = 6) SP/SP MHHI-A (n = 6)

Total = .79
Emotional = .95
Social = .53

SP/LP MHHI-A (n = 6)

Total = .93
Emotional = .85
Social = .85

Total = .93
Emotional = .95
Social = .81

LP/SP MHHI—A (n = 6)

Total = .92
Emotional = .81
Social = .85

 

65

Critical-Difference Scores
Ninety-five percent confidence intervals were calculated using the formula

recommended by Demorest and Walden (1984):

(x; — x1) : 2 425,,

where x; and x1 are inventory scores on two respective occasions, ‘12— s, is the standard
error of the difference, and 2 V2— se is the critical-difference score (at the 95% confidence
interval). Test-retest scores were used in all calculations. The critical-difference score is
the change in score from one session to another that represents a statistically significant
change. It is important in the context of this study because it provides examiners who
administer the MHHI with a minimum value that signifies when a difference in two scores
is large enough not to be attributable to chance. Such a value, particularly in view of the
high overall test-retest reliability observed for the MHHI, is needed to be able to conclude
that any aural rehabilitative intervention (e.g., hearing aids) is exerting a statistically
significant effect.

Critical-difference scores for various experimental subgroups are presented in
Table 4.11. Values ranged rather narrowly from 7.1 (SP/SP) to 8.7 (LP/SP). The critical-
difference scores of the MHHI are similar to results from a previous study. Newman,
Jacobson, Hug, Weinstein, and Malinoff (1991), who found a difference of 9.3 to indicate
a true change in the HHIE-S score, suggested that a change of 10 or more would indicate
a true change in scores for clinical purposes. Our overall findings suggest that a change in

MHHI scores of at least 9 on different administrations would be adequate as an indicator

of a true difference. Given that the test scores on the MHHI increment only by even-
numbered values, the author recommends that a change in scores of at least 10 on

different administrations should be regarded as a significant difference.

Table 4.1 1: Critical-difference scores (95 % confidence interval).

 

 

Group Number of Subjects Critical-Difference Score
MHHI 36 7.9
MHHI-E 18 8.5
MHHI-A 18 7.3
LP/SP 12 8.7
SP/SP 12 7.1
SP/LP 12 8.0

 

Predictive Validity

As mentioned in the Review of Literature, one of the potential uses of the MHHI is
as a screening measure of hearing impairment. As a research question, the goal of a
predictive validity analysis was considered to be of secondary importance in the present
study, mainly because of the limited number of subjects. This limitation restricted the
distribution of subjects across a variety of degrees of audiometric hearing loss. Most of
our hearing-impaired subjects demonstrated only mild or mild-to-moderate hearing loss. In
addition, as explained earlier, hearing aid use served to disqualify some subjects from the

validity analysis. As this criterion selectively precluded the participation of some

67

hearing-impaired subjects, as opposed to normal-hearing subjects, it fiirther reduced the
number of hearing-impaired subjects whose data could be analyzed for predictive validity.

Despite these limitations, and despite the likelihood that they would produce
unfavorable outcomes, several validity analyses were performed on the available data of
the 27 eligible subjects. Sensitivity, specificity, and false-positive and false-negative rates
were calculated for various MHHI cutoff scores, Pearson r’s for MHI-H scores and
selected audiometric indices were calculated, and the mean MHHI scores were calculated
for different definitions of hearing loss.

First, the sensitivity and specificity for the MHHI were calculated using various
MHHI cutoff points and various criteria for defining hearing impairment. MHHI cutoff
scores included 2, 4, 8, 10, 16, and 24. These cutoffs were chosen based on the
Lichtenstein, Bess, and Logan (1988a) study. The various definitions of hearing loss
included: High Frequency Pure Tone Average (HFPTA) > 20 dB HL, High Frequency
Pure Tone Average (HFPTA) > 25 dB HL, Speech Frequency Pure Tone Average
(SFPTA) > 20 dB HL, Speech Frequency Pure Tone Average (SFPTA) > 25 dB HL,
Speech Reception Thresholds (SRT) > 20 dB HL, Speech Reception Thresholds (SRT) >
25 dB HL, Word Recognition Scores < 90%, and the Ventry and Weinstein (1982 and
1983) criteria.
The data appear in Tables 4.12- 4.17. Sensitivity values ranged from 11.1 % to 55.6 %
and specificity values ranged from 3.7 % to 81.8 %. These results show inadequately low

sensitivity and specificity values. Outcomes were little affected by criteria used to define

68

hearing loss. Only the use of an extremely high MHHI cutoff score, 24, resulted in

reasonably high specificity values, but still at the cost of low sensitivity. Results differ from

results of previous studies. Lichtenstein, Bess, and Logan (1988a), using an HHIE-S

cutoff score of 8, obtained sensitivity values ranging from 53-72% and specificity values

ranging from 70-84% against differing definitions of hearing loss.

Table 4.12: Sensitivity, specificity, false-positive, and false-negative rates using an
MHHI cutofl score of 2, for various definitions of hearing impairment.

 

 

Criteria Sensitivity Specificity False Positive False Negative
HFPTA > 20 55.6% 7.4% 37.0% 0 %
HFPTA > 25 44.4% 3.7% 51.8% 0 %
SFPTA > 20 29.6% 7.4% 63.0% 0 %
SFPTA > 25 18.5% 7.4% 74. 1% 0 %

SRT > 20 37.1% 7.4% 55.6% 0 %
SRT > 25 25.9% 7.4% 66.7% 0 %
WRS < 90% 18.5% 7.4% 74.1% 0 %
Ventry & Weinstein 11.1% 7.4% 81.5 % 0 %

 

Table 4.13: Sensitivity, specificity, false-positive, and false-negative rates using an
MHHI cutofl score of 4, for various definitions of hearing impairment.

 

 

Criteria Sensitivity Specificity False Positive False Negative
HFPTA > 20 55.6% 11.1% 33.3% 0 %
HFPTA > 25 44.4% 7.4% 44.4% 0 %
SFPTA > 20 29.6% 11.1% 59.3% 0 %
SFPTA > 25 18.5% 11.1% 70.4% 0 %

SRT > 20 33.3% 11.1% 55.6% 0 %
SRT > 25 25.9% 11.1% 63.0% 0 %
WRS <90% 14.8% 11.1% 74.1% 0%
Ventry & Weinstein 18.5% 11.1% 70.4% 0 %

 

69

Table 4.14: Sensitivity, specificity, false-positive, and false-negative rates using an
MHHI cutoff score of 8, for various definitions of hearing impairment.

 

 

Criteria Sensitivity Specificity False Positive False Negative
HFPTA> 20 51.8% 25.9% 18.5% 3.7%
HFPTA > 25 44.4% 29.6% 25.9% 0 %
SFPTA > 20 33.3% 29.6% 37.0% 0 %
SFPTA > 25 18.5% 29.6% 51.8% 0 %

SRT > 20 33.3% 29.6% 37.0% 0 %
SRT > 25 25.9% 29.6% 44.4% 0 %
WRS < 90% 14.8% 29.6% 55.6% 0 %
Ventry & Weinstein 18.5% 29.6% 51 .8% 0 %

 

Table 4.15: Sensitivity, specificity, false-positive, and false-negative rates using an

MHHI cutofl score of 10, for various definitions of hearing impairment.

 

 

Criteria Sensitivity Specificity False Positive False Negative
HFPTA>20 44.4% 33.3% 11.1% 11.1%
HFPTA > 25 37.0% 37.0% 18.5% 7.4%
SFPTA > 20 25.9% 37.0% 29.6% 7.4%
SFPTA > 25 18.5% 44.4% 37.0% 0 %

SRT > 20 25.9% 37.0% 29.6% 7.4%

SRT > 25 22.2% 40.7% 33.3% 3.7%

WRS < 90% 14.8% 44.4% 40.7% 0 %
Ventry & Weinstein 18.5% 44.4% 37.0% 0 %

 

Mulrow, Tuley, and Aguiar (1990) found the HHIE-S to have a sensitivity of 79%,

although they reported a moderately high false-positive rate. With an MHHI cutoff of 4

and a hearing loss defined as the High Frequency Pure Tone Average (HFPTA) of 20 dB

HL or greater in this study, the highest sensitivity was measured at 55.6%. The false-

positive rate, however, was 33.3%, and the specificity was 11.1%

70

Table 4.16: Sensitivity, specificity, false-positive, and false-negative rates using a MHHI

cutofl score of 16, for various definitions of hearing impairment.

 

 

Criteria Sensitivity Specificity False Positive False Negative
HFPTA> 20 33.3% 33.3% 11.1% 22.2%
HFPTA > 25 29.6% 40.7% 14.8% 14.8%
SFPTA > 20 22.2% 44.4% 22.2% 11.1%
SFPTA > 25 18.5% 55.6% 25.9% 0 %

SRT > 20 22.2% 44.4% 22.2% 11.1%

SRT > 25 18.5% 48.1% 25.9% 7.4%

WRS < 90% 14.8% 55.6% 29.6% 0 %
Ventry & Weinstein 18.5% 55.6% 25.9% 0 %

 

Table 4.1 7: Sensitivity, specificity, false-positive, and false-negative rates using an

MHHI cutoff score of 24, for various definitions of hearing impairment.

 

 

Criteria Sensitivity Specificity False Positive False Negative
HFPTA > 20 11.1% 44.4% 0 % 44.4%
HFPTA>25 11.1% 55.6% 0% 33.3%
SFPTA > 20 11.1% 66.7% 0 % 22.2%
SFPTA > 25 7.4% 81.8% 3.7% 7.4%
SRT > 20 7.4% 63.0% 3.7% 25.9%
SRT > 25 7.4% 70.4% 3.7% 18.5%
WRS < 90% 7.4% 81.5% 3.7% 7.4%

Ventry & Weinstein 11.1% 81.5% 0 % 7.4%

 

As already mentioned, likely explanations for the differences in sensitivity and

specificity outcomes for the MHHI and the other versions of the HHI relate to the number
of subjects in our sample and the restricted degree of hearing loss exhibited by the sample.
While this study had only 27 eligible subjects for the analysis, Lichtenstein, Bess, and
Logan (1988a) studied 178 subjects and Mulrow, Tuley, and Aguilar (1990) studied 137

hearing-impaired subjects and 101 normal-hearing subjects.

71

The second method of assessing validity involved the calculation of Pearson
product—moment correlations between the MHHI scores and differing audiometric data.
Audiometric data used in the analysis included: Speech Frequency Pure Tone Average
(SFPTA), Speech Reception Threshold (SRT), the High Frequency Pure Tone Average

(HF PT A), Word Recognition Scores (WRSs), and the Speech Intelligibility Index ($11), or

Articulation Index (AI) (Mueller and Killion, 1990).

Results are shown in Table 4.18 for the overall MHHI score, MHHI scores by the

two age subgroups, and by the three experimental subgroups. As noted in the Review of

Table 4.18: Correlations between MHHI scores and selected audiometric indices.

 

 

Criteria MHHI MHHI-E MHHI-A LP sr sr
_ (LP/SP) (SP/SP) (SP/LP)
SFPTA 0.67 ** 0.55 0.74 ** 0.30** 0.47 0.61*
SR’T 0.57 ** 0.42 0.66 ** 0.75 ** 0.54 0.44
IIFrTA 0.62 ** 0.68 * 0.58 * 0.66 * 0.54 0.55
WRS - 0.50 ** -0.38 -0.66 ** -023 -027 -073 **
_ SII (AI) - 0.61 ** -0.62 * -0.61 * -0.66 * -040 0.24

 

a"-S'igrzificant at 0.05 level: **significant at 0. 01 level

Literature, correlations are not expected to be very high due to the fact that the Hearing
I“I‘ll'lciicap Inventories are not a direct measure of hearing loss, but rather a measure of
hearing handicap. It is expected that the MHHI score will generally rise with increasing
degree of hearing loss, but that the degree of correlation between the MHHI and
a‘1<1iometric hearing loss will be only modest. Essentially all the correlations were in the
dir€=<ztion expected. The only exception was the SH for the SP condition; the value of 0.24

was not statistically significant, however. Our data showed audiometric data to account

72

for 25-45% of the overall MHHI score for the various audiometric criteria. These results
are consistent with those of Ventry and Weinstein (1983), who found audiometric
measures to account for 3 1-3 8% of the variance in HHI scores. For the MHHI-E and the
MHI-II—A scores, the audiometric data account for 14-5 5% of the variance. Interestingly,
the audiometric data accounted for 8-64% of the variance when subjects’ MHHI scores

were based on the long program, whereas the audiometric data accounted for 6-3 7% of

the variance for subjects administered the short program.

Lastly, all eligible subjects (n = 27) were divided into different classifications of
hearing impairment based on audiometric data. Tables 4.19 - 4.25 show the mean MHHI
scores and standard deviations for the normal-hearing and hearing-impaired subjects.
Audi ometric data included were: Speech Reception Thresholds (SRTs) with 20- and 25-
(13 PE cutoffs, Word Recognition Score (WRS), Speech Frequency Pure Tone Average
(SFP TA) with 20- and 25- dB HL cutoffs, and High Frequency Pure Tone Average
(PIFPTA) with 20- and 25- dB HL cutoffs. The WRS cutoffs for excellent scores versus
80°C! and fair scores were chosen based on current clinical practice. Based on data from
Thornton and Raffin (1978), a subject’s score would need to change significantly to be
considered different (e. g., a score would typically need to change from the excellent range
to the fair range to be considered a significantly different score). Thus it is highly unlikely
that individuals whose word recognition scores fall just on either side of a 90% cutoff
Segre can be considered to have different scores, or that they should be expected to

perform differently from one another on the MHHI.

73

For all audiometric data and cutoffs, as the hearing impairment increased, the mean
MHHI score increased. For normal-hearing subjects, the mean MHHI score was 10-11,
irrespective of audiometric criterion. Mild hearing loss was associated with mean scores
ranging fiom 14-22, while moderate hearing loss (N=4) was associated with a mean score
of 23 - Ventry and Weinstein (1982) found the same trend for the HHIE. Despite the
restricted range of hearing sensitivity shown by our subjects, these latter results show
promise that the MHHI may ultimately be shown to have predictive validity equivalent or

similar to that of its non-computerized predecessors.

Tab 1e 4.19: Mean Il/IHHI scores and standard deviations for normal-hearing and
hearing-impaired subjects, as classified by the Speech Reception Threshold (SR7) with a
2 O—CiB HL cutoff

g

 

 

SRT (20—dB Cutoff) Mean SRT Mean MHHI MHHI Standard
\ Deviation
NORMAL HEARNG 9.4 dB HL
(0 - 20 dB HL) (n = 20) 10.8 7.7

MILD HEARING LOSS 29.0 dB HL
L (21 - 40 dB HILL (n = 7) 18.3 6.6

74

Table 4. 20: Mean MHHI scores and standard deviations for normal-hearing and
hearing-impaired subjects, as classified by the Speech Reception Threshold (SR7) with a
25-dB HL cutoff

 

 

SRT (ZS-dB Cutoff) Mean SRT Mean MHHI MHHI Standard
Deviation
NORMAL HEARING 8.0 dB HL 10.6 7.9
(0-25dBHL) (n=18)
MIIJ) HEARING LOSS 28.89 dB HL 17.1 6.6
(26-40dBI-IL) (n=9)

 

Tab le 4. 21: Mean MHHI scores and standard deviations for normal-hearing and
hearing-impaired subjects, as classified by the Word Recognition Score (WRS).

 

WRS Mean WRS Mean MHHI MHHI Standard
\ Deviation
EXCELLENT 96.18 % 10.4 6.7
(91 - 100%) (n = 22)
GOOD 86.5 % 24.0 3.3
(81 - 90%) (n = 4)
FAIR 70 % 20.0 _
c (61 - 80%) (n = 1)

 

Table 4. 22: Mean MHHI scores and standard deviations for normal-hearing and
eating-impaired subjects, as classified by the Speech Frequency Pure Tone Average
(SFITA) with a 20-dB HL cutoff

L

SFPTA (20—dB Cutoff) Mean SFPTA Mean MHHI MHHI Standard

 

\ Deviation
NORMAL HEARING 7.41 dB HL 10.0 6.9
(0-20dBI-IL) (n=18)
MILD HEARING LOSS 28.7 dB HL 18.2 7.6
{___ (21-40dBHL) (n=9)

 

75

Table 4. 23: Mean MHHI scores and standard deviations for normal-hearing and
hearing-impaired subjects, as classified by the Speech Frequency Pure Tone Average
(SFP TA) with a 25-dB HL cutofif

 

SF PTA (ZS-dB Cutoff) Mean SFPTA Mean MHHI MHHI Standard

 

_ Deviation
NORMAL HEARING 10.08 dB HL 10.6 7.3
(0 - 25 dB HL) (n = 22)
MIIJ) HEARING LOSS 32 dB HL 22.0 2.0
(26-40 dB HL) @=5)

 

Table 4. 24: Mean .MHHI scores and standard deviations for normal-hearing and
hearing-impaired subjects as classified by High Frequency Pure Tone Average (HFP TA)
with a 20-dB HL cutoflf

HFPTA (20-dB Cutoff) Mean HFPT A Mean MHHI MHHI Standard

 

\ Deviation
NORMAL HEARING 8.97 dB HL 7.8 6.7
(0-20dBHL) (n=12)
MILD HEARING LOSS 30.76 dB HL 14.4 6.3
(21-40dBHL) (n=11)
MODERATE HEARING 46.68 dB HL 23.0 3.8

‘

Loss (41 - 50 dB HL) (n = 4)

76

Table 4. 25: Mean MHHI scores and standard deviations for normal-hearing and

hearing—impaired subjects as classified by High Frequency Pure Tone Average (HFP TA)
with a 25-dB HL cutofl

 

HFPTA 25-dB Cutoff Mean HFPTA Mean MHHI MHHI Standard

 

Deviation
NORMAL HEARING 11.15 dB HL 8.9 6.9
(0-25 dB HL) (n = 15)
MIIJ) HEARING LOSS 32.93 dB HL 14.7 6.5
(26-40dBI-IL) (n=8)
MODERATE HEARING 46.68 dB HL 23.0 3.8
LOSS (n = 4)
(41 - 50 dB HL)

 

Subject Choices on the MHHI

Respondents who take the long program of the MHHI are offered several choices
before beginning the questionnaire section. Among the choices chosen for analysis were
the extent to which: (1) respondents chose whether to go through the Computer
Inb‘oduction, (2) they preferred to listen to a male’s voice or a female’s voice, and (3)
they chose to use the ILLUSTRATE or REPHRASE capabilities.

Subjects who use the LP version first have the option of receiving an introduction
to the computer. Table 4.26 reports the percentages of subjects who used that option. Of
the 12 subjects who had the option to go through the Computer Introduction during the
firS1: experimental session (LP/SP), 50% (6/12) chose to do so. Of those who had the
option at the second session (SP/LP), 8.3% (1/12) chose it. Presumably, the experience of

thi 8 group in operating the computer during the initial (SP) session was sufficient to make

77

the majority feel comfortable with its operation. Overall, five of the 12 elderly subjects
(41.7%) who had the option chose to do so, with the majority (58.3%) choosing not to
view the introduction. Two of the 12 adults given the option (16.7%) chose to take it,
while 83.3% chose not to take it. Thus while most subjects in either age group chose to
circumvent the Computer Introduction, elderly adults were more prone to view the

introduction than younger adults.

Table 4.26: Subjects’ use of the Computer Introduction section of the MHHI.

 

 

Option Category Computer Introduction No Computer

(n = 12 per Category) Introduction
First-Session Option 50.0% 50.0%
Second-Session Option 8.3% 91.7%
Elderly adult subjects 41.7% 58.3%
_ Adult subjects 16.7% 83.3%

 

For subjects in the two groups who were administered the LP version, exactly 1/3
(3 3 - 3 %) chose the male voice and 2/3 (66.7%) chose the female voice. Slightly more than
half the subjects (58.3%) chose the gender of the speaker that was opposite their own. Of
tho se who either chose the male voice during the long program or were administered the
male voice by default during the short program (SP/SP or SP/LP), 58.3% chose the
fetTlale voice in the second session.

Each subject, in either the LP or SP versions of the program, had the option of
h€l\’ing questions illustrated or rephrased. This option is explained only within the long

prOgram. Of those who did not have this option explained (SP/SP), none (0%) used the

78

ILLUSTRATE or REPHRASE features. Of those who had the option explained in the
first LP session (LP/SP), one of the 12 (8.3%) used the REPHRASE option two times. Of

those who took the long program during the second session (SP/LP), two subjects
(16. 7%) used the ILLUSTRATE and REPHRASE options. ILLUSTRATE was chosen
three times and REPHRASE was chosen twice by the two subjects. Results of this analysis

sugge st that while these options may be useful to some subjects, they are not a critical

feature of the questionnaire.

Etit- Questionnaire Analysis
Subjects completed an exit questionnaire regarding the MHHI at the end of the

second session. Depending on whether a given subject had completed only a short

pr Ogram version of the MHHI (SP/ SP) or had completed the long program version in
either the LP/ SP or SP/LP groups, a corresponding exit-interview questionnaire was
administered. Results from the short program’s exit questionnaire are presented in Tables

4 - 2‘7 and 4.28, while results from the long program’s exit questionnaire are shown in

Tables 4.29 and 4.30.

79

Table 4. 2 7: Exit-questionnaire results for subjects performing only the short program

 

 

(SP/SP).
Question Mean Standard Deviation Mode
#l The Multimedia Hearing
Handicap Inventory program was 4.7 1.1 5
easy to use.
#2 The voice was easy to hear. 4.9 0.3 5
#3 The voice was easy to 4.8 0.4 5
understand.
#4 The text was easy to read. 4.7 0.6 5
#5 I found the rephrasing of the 3 .7 1.5 5
questions helpful.
#6 I found the illustrations of the 3.9 1.2 5
questions helpful.
#7 The Hearing Profile given to me 4.4 1.2 5

at the end of the program was
easy to understand.

#8 I will follow the suggestions 4.7 0.7 5
given to me in the Hearing
Profile.

‘

(1 l: Strongly Disagree, 3 = Neutral, 5 = Strongly Agree)

80

Table 4. 28: Exit-questionnaire results for subjects performing the long program in either
session (LP/SP or SP/LP).

k

 

Question Mean Standard Deviation Mode
#1 The Multimedia Hearing 4.9 0.4 5
Handicap Inventory program was
easy to use.
#2 I found the section on the use of 4.3 0.8 5
the computer to be helpfiil.
#3 I found the rephrasing of the 3 .7 0.8 3
questions helpfiil.
#4 I found the illustrations of the 4.5 0.7 5
questions helpfiJl.
#5 I learned some useful information 4.2 0.9 4
about hearing loss from the
program.
#6 The voice was easy to hear. 5.0 0 5
#7 The voice was easy to 5.0 0.2 5
understand.
#8 The text was easy to read. 5.0 0.2 5
#9 The directions on how to use the 4.8 0.4 5
program were easy to
understand.
#10 I learned some useful 4.0 1.0 4

information about the treatments
for hearing loss.

# 1 l The Hearing Profile given to 4.8 0.4 5
me at the end of the program was
easy to understand.

# 1 2 I will follow the suggestions 4.7 0.4 5
given to me in the Hearing
Profile.

(1 2 Strongly Disagree, 3 = Neutral, 5 = Strongly Agree)

81

Table 4. 29: Comfort level reported with selected technologies by subjects performing the
short program only (SP/SP).

‘

 

Device Mean Standard Deviation Mode(s)
Manual Typewriter 3.5 1.5 5
Calculator 4.2 0.7 4 and 5
Adding Machine 4.2 1.4 5
Electric Typewriter 3.7 1.4 5
Computer without a mouse 3.3 1.4 2 and 5
Computer with a mouse 4.] 0.9 5

 

(1 = very uncomfortable, 3 = neutral, 5 = very comfortable)

Table 4. 30: Comfort level reported with selected technologies by subjects performing the
long program in either session (LP/SP or SP/LP).

 

 

Device Mean Standard Deviation Mode(s)
Manual Typewriter 3.8 1.3 5
Calculator 4. 1 1.2 5
Adding Machine 3.9 1.2 5
Electric Typewriter 3.7 1.4 4 and 5
Computer without a mouse 3.1 1.6 1 and 5
Computer with a mouse 3.6 1.5 5

 

(1 = very uncomfortable, 3 = neutral, 5 = very comfortable)

Subjects generally responded positively to the design and the functional
characteristics of the MHIH. Further, they indicated that they learned from the program
and that they intended to follow the suggestions given in the Hearing Profile. Although
subj ects in the SP/ SP group (Table 4.27) rated the REPHRASE and ILLUSTRATE
Options moderately helpful (neutral to agree), our previously described analysis indicated
that none of them actually used either feature. Subjects’ ratings of comfort with the
Various technologies were generally in the neutral to comfortable range of the rating scale

(Tables 4.29 and 4.30).

82

Three subjects did use the ILLUSTRATE or REPHRASE option. All three
subjects had taken the long program in one of the two sessions and used both options
during the long program administration only. Two subjects used the REPHRASE option
only and one subject used both the ILLUSTRATE and REPHRASE options. These
subjects gave the option of REPHRASE an average rating of 3.0. The responses ranged
from 0 (subject lefi blank with a note they had not used the option) to 5 (rated very
helpful), with the third subject rating the option a 4. The subject who used the
ILLUSTRATE option rated it a 3. Caution should be taken in interpreting these results,
given the small number of subjects covered in this analysis.
Seven subjects used the Computer Introduction option of the long program.
Six of the seven were administered the long program at the first session, with the seventh
subject completing the long program at the second session. These subjects rated their
comfort with computers (either with or without a mouse) a mean of 2.4 and a mode of 1
(l = very uncomfortable and 5 = very comfortable). Subjects who choose not to use the
Computer Introduction option rated their comfort with computers (either with or without
a mouse) a mean of 3.7. Again, caution should be taken in interpreting these results, given
the few number of subjects who chose to use the Computer Introduction option.
Data from the exit questionnaires should generally be interpreted with caution.
Mean responses on the Likert scale were rarely anything other than the extreme number 5.
While it might be that the design of the MHHI was in fact very satisfactory, it is also

DOSsible that subjects were reserved in their criticism of the program. It is important to

83

IIOte that subjects were asked to rate their level of comfort, and not their level of
exPerience or expertise, with the various technologies.
The comfort ratings were elicited to determine the extent to which subjects’
resDonses might be related to their responses to the design and function (i.e., the utility) of
[be IVlHl-II. This relationship, as well as the relationships between educational and income

levels and responses on the design and firnctional utility questions of the exit interview, are
addressed in Table 4.31 and Table 4.32. For the Spearman rank-order correlations (rho
analyses) in these tables, the categorical educational and income variables (Table 3.3 and
Table 3.4, respectively) were converted to ranked values. The educational response of
“Did not complete High School” was assigned the value of 1 and a response of
“Professional or Doctoral Degree” was assigned the value of 5. An income range response
of $0 - $15,000 was assigned the value of 1 and the income range of $75,000 or more was
assigned the value of 5. Intermittent values were ranked accordingly. Utility values for this
analysis were taken from the ranks (1-5) referred to in the data from Tables 4.27 and 4.28,
as appropriate.

Table 4. 31: Spearman rho ’s for utility, income, education, and technology comfort for
the SP/SP test group.

 

 

_ Utility Comfort Education Income
Utility -- -0.22 0.20 0.02
Comfort -- -- 0.22 -0.01
Education -- -- -- 0.35
__ Income -- -- -- --

 

84

Table 4. 32: Spearman rho ’s for utility, income, education, and technology comfort for
the LP/SP and SP/LP test groups.

 

 

\
\ Utility Comfort Education Income
Utility -- -0.22 -0. l 1 -0.06
Comfort -- -- 0.37 0.30
Education -- -- -- 0.48 *

_ Income -- -- .. --
4" Correlation is significant at the 0.05 level (2-tailed).

’

Spearman rho results indicate that there was little correlation between the subjects
perceptions of the usefulness of the program and their education, income, or comfort level
with the selected technologies. For the subjects who were assigned to either the LP/ SP
test condition or the SP/LP test condition, the Spearman rho was significant for the
education versus income conditions. Thus for these subjects, the higher their education,
the higher was their income. Overall, these results indicate that the subjects’ perceptions
of the program were not closely associated with their socioeconomic status or the level of

comfort they felt with the various technologies.

85

Chapter 5

Conclusion

The major purposes of previous versions of the Hearing Handicap Inventories, as
O’C’SCribed by a number of recent investigators, include their use as a tool for: (1) screening

for hearing loss, (2) measurement of hearing handicap, (3) measurement of outcomes-
assessment of hearing aid benefit and other forms of aural rehabilitation, and (4)
establishing hearing aid candidacy and use. In this study, it was firmly established that the
Nil-IP11 is a reliable tool that can be used on a test-retest basis to measure hearing handicap
and to assess outcomes of audiologic rehabilitation. An individual who is administered the
MHHI in one session can be expected to exhibit approximately the same score during a
subsequent session if his or her hearing status remains stable and there has been no
rehabilitative intervention. The MHHI can be administered prior to a hearing aid fitting
and, after a designated period of hearing aid use, the MHHI can be re-administered. If the
score has improved by 10 or more, it can be concluded that the intervention of hearing
aids has produced a perceived benefit, or reduction in hearing handicap. This suggested
critical-difference value of 10 is highly consistent with earlier research on paper-and-pencil
versions of the HHIE-S and HHIA-S.

The MHHI also has high internal consistency reliability. Its test-retest and internal

consistency reliability generally apply to the test overall, as well as to its subscales.

86

While this study did not specifically address the MHHI as a tool for establishing
hearing aid candidacy and prediction of successful hearing aid use, there is no reason to
b‘elieve that the multimedia version of the HHI questionnaires would be any less capable
thall the pencil-and-paper or face-to-face interview versions in these regards. Newman et

31: (1991) observed that if the I-HiIE-S score is greater than about 10, but less than 18, an
individual is highly likely to have a hearing impairment, but is less likely to seek out or
successfiilly use hearing aids than someone whose score is 18 or greater. In this study,
hAI—II-fl scores of subjects who wore hearing aids reflected aided benefit, but our ability to
perform this type of analysis was limited because many of the subjects’ MHHI scores were
less than 18—reflecting their relatively mild hearing impairments.

Predictive validity of the MHHI was not amply demonstrated in this study, based
on the limited number of subjects. The study did reveal, however, that subjects who
scored relatively high on the MHHI tended to have greater hearing impairment. Although
this finding provides only preliminary evidence of the relationship between the MHHI
score and hearing impairment, that evidence, along with previous research on the
screening versions of the HHI, suggests that a reasonable approach is to use a minimum
MHHI score of 10 for the identification of hearing loss. This approach seems reasonable at
least until further research reveals a more-optimum value. As the mean score of our
normal-hearing subjects was around 10, and the range of scores of mildly hearing-impaired
SUPj ects was 14-22, examiners should be aware of the probable overlap of MHHI scores

within these groups of listeners. Examiners should be especially mindful of the high false-

87

Positive rate observed with most audiometric cutoff values utilized in the limited sample of
this study.

This investigation raises several questions regarding the MHHI that are worthy of

1hrther study. Because a major potential use of the MHHI may be in hearing screenings,
ll‘Jl‘ther study of its predictive validity is essential. A relatively small number of subjects
was available for the predictive validity analysis in this experiment, which was aimed
primarily at a detemrination of test-retest reliability. A serious study of sensitivity,
specificity, and false-positive and false-negative rates requires a larger number of subjects
than used here. In addition, subjects should exhibit a broader range of hearing impairment
than was true in our sample.

The possibility exists that in the clinical setting, a subject may have already
completed the paper-and-pencil HHI or may have been asked the HHI questions verbally
before being administered the MHHI. The test-retest reliability across the different forms
of administration should be specifically explored.

Subjects in this study responded favorably to the MHHI’s features, rating it high
on features that reflect its clinical utility. Given the relative non-use of the REPHRASE
and ILLUSTRATE features, the usefirlness of this particular feature in open to question.
In fiiture studies, respondents should be actively encouraged to use these features
routinely, and their effect on reliability evaluated.

Lastly, the MHHI Hearing Profile includes specific, individualized

recommendations for follow-up. Most participants in this study indicated that they would

88

follow these recormnendations. There was no attempt, however, to determine whether
they actually did comply with the recommendations, which, in the case of hearing-impaired
individuals, included the recommendation to schedule appointments for hearing and
heaHing aid evaluations. The degree to which those recommendations are associated with
compliance behavior should be studied, particularly in relation to tenets of the Health

Belief Model. In the end, the potential to improve audiologic compliance behavior could

be the MHHI’s greatest virtue.

89

APPENDICES

9O

 

Appendix A

Hearing Handicap Inventory for the Elderly (HHIE)

The purpose of this scale is to identify the problems your hearing loss may cause you.
Circle Yes, Sometimes, or No for each question. Do not skip a question if you avoid a
situation because of your hearing problem. If you use a hearing aid, please answer the

way you hear with the aid

S— 1 Does a hearing problem cause you to use the phone less often than you would like?
Yes Sometimes No

E-Z Does a hearing problem cause you to feel embarrassed when meeting new people?
Yes Sometimes No

S-3 Does a hearing problem cause you to avoid groups of people?
Yes Sometimes No

E-4 Does a hearing problem make you irritable?
Yes Sometimes No

E-S Does a hearing problem cause you to feel fi'ustrated when talking to members of your
family?
Yes Sometimes No

S-6 Does a hearing problem cause you difficulty when attending a party?
Yes Sometimes No

E-7 Does a hearing problem cause you to feel “stupid” or “dumb”?
Yes Sometimes No

S-8 Do you have difficulty hearing when someone speaks in a whisper?
Yes Sometimes No

E-9 Do you feel handicapped by a hearing problem?
Yes Sometimes No

S-IO Does a hearing problem cause you difficulty when visiting friends, relatives, or

neighbors?
Yes Sometimes No

91

 

S- 11 Does a hearing problem cause you to attend religious services less often than you
would like?
Yes Sometimes No

E- 12 Does a hearing problem cause you to be nervous?
Yes Sometimes No

S- 13 Does a hearing problem cause you to visit fiiends, relatives, or neighbors less ofien
than you would like?
Yes Sometimes No

E— 1 4 Does a hearing problem cause you to have arguments with family members?
Yes Sometimes No

S— 1 5 Does a hearing problem cause you difficulty when listening to the TV or radio?
Yes Sometimes No

S- 1 6 Does a hearing problem cause you to go shopping less often than you would like?
Yes Sometimes No

E- 1 7 Does a hearing problem or difficulty with your hearing upset you at all?
Yes Sometimes No

E- 1 8 Does a hearing problem cause you to want to be by yourself?
Yes Sometimes No

S- 1 9 Does a hearing problem cause you to talk to family members less ofien than you
would like?

Yes Sometimes No

E-ZO Do you feel that any difficulty with your hearing limits or hampers your personal or
social life?
Yes Sometimes No

S-2 1 Does a hearing problem cause you difficulty when in a restaurant with relatives or
friends?

Yes Sometimes No

E-22 Does a hearing problem cause you to feel depressed?
Yes Sometimes No

92

5—23 Does a hearing problem cause you to listen to TV or radio less often than you would
like?
Yes Sometimes No

E—24 Does a hearing problem cause you to feel uncomfortable when talking to fiiends?
Yes Sometimes No

E—25 Does a hearing problem cause you to feel left out when you are with a group of
people?
Yes Sometimes No

For Clinician’s Use Only: Total Score:
Subtotal E:
Subtotal S:

 

 

 

93

Appendix B

Hearing Handicap Inventory for the Elderly—Screening Version (HHIE—S)

The purpose of this scale is to identijy the problems your hearing loss may cause you.
Circle Yes, Sometimes, or No for each question. Do not skip a question if you avoid a

situation because of your hearing problem. If you use a hearing aid, please answer the

way you hear with the aid
1 . Does a hearing problem cause you to feel embarrassed when you meet new people?
Yes Sometimes No
2. Does a hearing problem cause you to feel frustrated when talking to members of your

family?
Yes Sometimes No

3. Do you have difficulty hearing when someone speaks in a whisper?
Yes Sometimes No

4. Do you feel handicapped by a hearing problem?

Yes Sometimes No

5. Does a hearing problem cause you difficulty when visiting fiiends, relatives or

neighbors?
Yes Sometimes No

6. Does a hearing problem cause you to attend religious services less often than you would

like? ‘
Yes Sometimes No

7. Does a hearing problem cause you to have arguments with family members?
Yes Sometimes No

8- Does a hearing problem cause you difficulty when listening to TV or radio?
Yes Sometimes No

9. Do you feel that any difficulty with your hearing limits or hampers your personal or

social life?
Yes Sometimes No

94

1 0. Does a hearing problem cause you difficulty when in a restaurant with relatives or
fiiends? Yes Sometimes No

95

Appendix C

Hearing Handicap Inventory for Adults (HHIA)

The purpose of this scale is to identify the problems your hearing loss may cause you.
Circle Yes, Sometimes, or No for each question. Do not skip a question if you avoid a

situation because of your hearing problem. If you use a hearing aid, please answer the

way you hear with the aid

S-l Does a hearing problem cause you to use the phone less often than you would like?
Yes Sometimes No

E-2 Does a hearing problem cause you to feel embarrassed when meeting new pe0ple?
Yes Sometimes No

S-3 Does a hearing problem cause you to avoid groups of people?
Yes Sometimes No

E—4 Does a hearing problem make you irritable?
Yes Sometimes No

E-S Does a hearing problem cause you to feel frustrated when talking to members of your

family?
Yes Sometimes No

S-6 Does a hearing problem cause you difficulty when attending a party?
Yes Sometimes No

S-7 Does a hearing problem cause you difiiculty hearing/understanding coworkers, clients,

or customers?
Yes Sometimes No

E-8 Do you feel handicapped by a hearing problem?
Yes Sometimes No

S-9 Does a hearing problem cause you difficulty when visiting friends, relatives, or

neighbors?
Yes Sometimes No

96

E-lO Does a hearing problem cause you to feel frustrated when talking to coworkers,
clients, or customers?
Yes Sometimes No

S-ll Does a hearing problem cause you difficulty in the movies or theater?
Yes Sometimes No

E-12 Does a hearing problem cause you to be nervous?
Yes Sometimes No

S-13 Does a hearing problem cause you to visit fiiends, relatives, or neighbors less often
than you would like?

Yes Sometimes No

E-14 Does a hearing problem cause you to have arguments with family members?
Yes Sometimes No

S-15 Does a hearing problem cause you difficulty when listening to the TV or radio?
Yes Sometimes No

S-16 Does a hearing problem cause you to go shopping less ofien than you would like?
Yes Sometimes No

E-l7 Does a hearing problem or difficulty with your hearing upset you at all?
Yes Sometimes No

E-18 Does a hearing problem cause you to want to be by yourself?
Yes Sometimes No

S-19 Does a hearing problem cause you to talk to family members less often than you
would like?

Yes Sometimes No

E-20 Do you feel that any difficulty with your hearing limits or hampers your personal or
social life?

Yes Sometimes No
S-21 Does a hearing problem cause you difficulty when in a restaurant with relatives or
friends?

Yes Sometimes No

E-22 Does a hearing problem cause you to feel depressed?
Yes Sometimes No

97

S—23 Does a hearing problem cause you to listen to TV or radio less ofien than you would
like?
Yes Sometimes No

E-24 Does a hearing problem cause you to feel uncomfortable when talking to fiiends?
Yes Sometimes No

E-25 Does a hearing problem cause you to feel lefi out when you are with a group of
people?
Yes Sometimes No

For Clinician’s Use Only: Total Score:
Subtotal E:
Subtotal S:

 

 

 

98

Appendix D

Hearing Handicap Inventory for Adults—Screening Version (HHIA-S)

The purpose of this scale is to identify the problems your hearing loss may cause you.
Circle Yes, Sometimes, or No for each question. Do not skip a question if you avoid a
situation because of your hearing problem. If you use a hearing aid, please answer the

way you hear with the aid

1. Does a hearing problem cause you to feel embarrassed when you meet new people?
Yes Sometimes No

2. Does a hearing problem cause you to feel frustrated when talking to members of your
family?
Yes Sometimes No

3. Do you have difficulty hearing or understanding co-workers, clients, or customers?
Yes Sometimes No

4. Do you feel handicapped by a hearing problem?
Yes Sometimes No

5. Does a hearing problem cause you difficulty when visiting fiiends, relatives or

neighbors?
Yes Sometimes No

6. Does a hearing problem cause you difficulty in the movies or in the theater?
Yes Sometimes No

7. Does a hearing problem cause you to have arguments with family members?
Yes Sometimes No

8. Does a hearing problem cause you difficulty when listening to TV or radio?
Yes Sometimes No

9. Do you feel that any difficulty with your hearing limits or hampers your personal or

social life?
Yes Sometimes No

99

10. Does a hearing problem cause you difficulty when in a restaurant with relatives or
fiiends?
Yes Sometimes No

100

Appendix E

Components of the Long Program of the
Multimedia Hearing Handicap Inventory (MHHI)

(1) Program Overview, which states the purpose of the program, distinguishes between
hearing impairment and hearing handicap, and informs the respondent that an
individualized Hearing Profile will be provided at the end of the program.

(2) Computer Introduction, in which respondents not familiar with computer operations
are guided through the hardware and operational components essential to use the
program. (This portion is optional.)

(3) Hearing Loss, which summarizes prevalence rates of hearing loss, common problems
experienced by persons with hearing impairment, how we hear, and how hearing
sensitivity is graphed on an audiogram. (This portion is optional.)

(4) MHHI Questionnaire, in which the age-appropriate screening version of the
questionnaire is administered to younger and older adults. Adults aged 60 years and
below are administered the HHIA-S, and those aged over 60 years are administered
the HHIE-S. Respondents are asked whether their answers are based on their wearing
of hearing aids or not (aided or unaided). The questionnaire consists of 10 items,
including five social-situational and five emotional items. ILLUSTRATE and
REPHRASE options are available to visualize or clarify the respective types of items.
The respondent needs only to click on Yes, Sometimes, or No to answer each question.

(5) Treatments for Hearing Loss, a summary of major treatment options for hearing
impairment. Treatments include medical, surgical, and audiological options. (This
portion is optional.)

(6) Hearing Profile, a printed set of individualized results and recommendations for
audiologic and medical follow-up, is given to each respondent at the end of the
program. The following types of information are included in the Hearing Profile:

Respondent Name, Respondent ID, Listening Condition, Date, Time,

Interpretation, Hearing Profile, Recommendations, Contact Information,
Disclaimer (see Appendix F for details of disclaimer)

101

Appendix F

Components of the MHHI Hearing Profile

(1) Respondent information, in which identifying information, including the respondent’s
name and identification number, listening condition, and date and time are printed.

(2) Interpretation, in which the range of possible scores and a basic interpretation of
scores are given.

(3) Hearing Profile, in which the respondent’s score, including the score obtained on a
previous administration (if applicable), is given. As appropriate, a summary of clinical
research on the relationships between hearing handicap scores and hearing loss, and
between hearing handicap scores and hearing aid use, is also given.

(4) Recommendations, based on the respondent’s score, which may include, as applicable,
referral to an audiologist or primary—care physician. This section includes options that
are recommended for the respondent to follow. Specific options depend on the hearing
handicap score and whether the listening condition is unaided or aided.

(5) Examiner information, consisting of the name, title, address and phone number of the
examiner.

(6) Disclaimer, indicating that the Hearing Handicap Inventory is not a direct test of the
respondent’s hearing, and that recommendations and referral information are based on
a comparison of the questionnaire score with scores obtained from samples of people
who have known hearing characteristics.

102

Appendix G

Protocol Design for Eight Hearing Profiles

103

HEARING PROFILE:
HEARING HANDICAP INVENTORY
(Profile 1)

(IF the current score is 0-9, AND a previous test result IS NOT found in the database for this
individual, AND the listening condition is Unaided, print the following)

Exarninee Name: Insert here

Examinee ID: Insert here

Listening Condition: Insert Unaided or Aided here
Date: Insert here

Time: Insert here

Interpretation: Scores indicate degree of hearing handicap; the higher the number, the greater the
perceived handicap associated with hearing impairment. The highest possible handicap score for a
given administration of the questionnaire is 40. Scores between 0-9 should be interpreted as no
perceived handicap, and scores between 10-40 represent varying degrees of perceived handicap.

Hearing Profile: Your hearing handicap score today was (insert score here). A score in this range
suggests either that there is no hearing loss, or if present, hearing loss is not interfering
substantially with communication or other activities in your daily life.

Recommendations: It is recommended that you return to complete this Hearing Handicap Inventory
in one year, or sooner if you should notice a change in your hearing. If you have any medical
problems such as pain or discharge from your ears, ringing or other sounds in your ears, or
dizziness, you should schedule an appointment with your primary-care physician.

Ifyou have any questions about this Hearing Handicap Inventory or its interpretation, please
contact:

(Insert name, title here)

(Insert address here)

(Insert phone number here)

Disclaimer: This has not been a direct test of your hearing. Recommendations and referral
information are based, in part, on a comparison of your questionnaire score with average scores
obtained from a sample of people having known hearing characteristics, and do not directly identify
hearing impairment or car pathology.

104

HEARING PROFILE:
HEARING HANDICAP INVENTORY
(Profile 2)

(IF the current score is 0-9, AND a previous test result IS NOT found in the database for this
individual, AND the listening condition is Aided, print the following)

Examinee Name: Insert here

Examinee ID: Insert here

Listening Condition: Insert Unaided or Aided here
Date: Insert here

Time: Insert here

Interpretation: Scores indicate degree of hearing handicap; the higher the number, the greater the
perceived handicap associated with hearing impairment. The highest possible handicap score for a
given administration of the questionnaire is 40. Scores between 0-9 should be interpreted as no
perceived handicap, and scores between 10-40 represent varying degrees of perceived handicap.

Hm‘ g Profile: Your hearing handicap score today was (insert score here). A score in this range
suggests that your hearing loss is not interfering substantially with communication or other
activities in your daily life, and that you are receiving ample benefit from your hearing aid(s).

Recommendations: It is recommended that you return to complete this Hearing Handicap Inventory
in one year, or sooner if you should notice either a change in your hearing or in the performance of
your hearing aid(s). If you have any medical problems such as pain or discharge from your ears,
ringing or other sounds in your ears, or dizziness, you should schedule an appointment with your

primary-care physician.

Ifyou have any questions about this Hearing Handicap Inventory or its interpretation, please
contact:

(Insert name, title here)

(Insert address here)

(Insert phone number here)

Disclaimer: This has not been a direct test of your hearing. Recommendations and referral
information are based, in part, on a comparison of your questionnaire score with average scores
obtained from a sample of people having known hearing characteristics, and do not directly identify
hearing impairment or ear pathology.

105

HEARING PROFILE:
HEARING HANDICAP INVENTORY
(Profile 3)

(IF the current score is 0-9, AND a previous test result for this individual IS found in the database,
AND the listening condition is Unaided, print the following:)

Examinee Name: Insert here

Examinee ID: Insert here

Listening Condition: Insert Unaided or Aided here
Date: Insert here

Time: Insert here

Interpretation: Scores indicate degree of hearing handicap; the higher the number, the greater the
perceived handicap associated with hearing impairment. The highest possible handicap score for a
given administration of the questionnaire is 40. Scores between 0-9 should be interpreted as no
perceived handicap, and scores between 10-40 represent varying degrees of perceived handicap.

Hearing Profile: Your hearing handicap score today was (insert score here). A score in this range
suggests either that there is no hearing loss, or if present, hearing loss is not interfering
substantially with communication or other activities in your daily life. Your previous score on
(insert date of last test here) was (insert last test score here). A difference in that score and today’s
score of less than 10 suggests no real change in perceived handicap, while a difference of 10 or
more suggests a possible change in perceived hearing handicap.

Recommendations: It is recommended that you return to complete this Hearing Handicap Inventory
in one year, or sooner if you should notice a change in your hearing. If you have any medical
problems such as pain or discharge from your ears, ringing or other sounds in your ears, or
dizziness, you should schedule an appointment with your primary-care physician.

If you have any questions about this Hearing Handicap Inventory or its interpretation, please
contact:

(Insert name, title here)

(Insert address here)

(Insert phone number here)

Disclaimer: This has not been a direct test of your hearing. Recommendations and referral
information are based, in part, on a comparison of your questionnaire score with average scores
obtained from a sample of people having known hearing characteristics, and do not directly identify
hearing impairment or car pathology.

106

HEARING PROFILE:
HEARING HANDICAP INVENTORY
(Profile 4)

(IF the current score is 0-9, AND a previous test result for this individual IS found in the database,
AND the listening condition is Aided, print the following)

Examinee Name: Insert here

Examinee ID: Insert here

Listening Condition: Insert Unaided or Aided here
Date: Insert here

Time: Insert here

Interpretatifli: Scores indicate degree of hearing handicap; the higher the number, the greater the
perceived handicap associated with hearing impairment. The highest possible handicap score for a
given administration of the questionnaire is 40. Scores between 0-9 should be interpreted as no
perceived handicap, and scores between 10-40 represent varying degrees of perceived handicap.

Hearing Profile: Your hearing handicap score today was (insert score here). A score in this range
suggests that your hearing loss is not interfering substantially with communication or other
activities in your daily life, and that you are receiving ample benefit from your hearing aid(s). Your
previous score on (insert date of last test here) was (insert last test score here). A difference in that
score and today’s score of less than 10 suggests no real change in perceived handicap, while a
difference of 10 or more suggests a possible change in perceived hearing handicap.

Recommendations: It is recommended that you return to complete this Hearing Handicap Inventory
in one year, or sooner if you should notice either a change in your hearing or in the performance of
your hearing aid(s). If you have any medical problems such as pain or discharge fiom your ears,
ringing or other sounds in your ears, or dizziness, you should schedule an appointment with your
primary-care physician.

Ifyou have any questions about this Hearing Handicap Inventory or its interpretation, please
contact:

(Insert name, title here)

(Insert address here)

(Insert phone number here)

Disclaimer: This has not been a direct test of your hearing. Recommendations and referral
information are based, in part, on a comparison of your questionnaire score with average scores
obtained from a sample of people having known hearing characteristics, and do not directly identify
hearing impairment or car pathology.

107

HEARING PROFILE:
HEARING HANDICAP INVENTORY
(Profile 5)

(IF the current score is 10 or more, AND a previous test result for this individual IS NOT found in
the database, AND the listening condition is Unaided, print the following)

Examinee Name: Insert here

Examinee ID: Insert here

Listening Condition: Insert Unaided or Aided here
Date: Insert here

Time: Insert here

Interpretation: Scores indicate degree of hearing handicap; the higher the number, the greater the
perceived handicap associated with hearing impairment. The highest possible handicap score for a
given administration of the questionnaire is 40. Scores between 0-9 should be interpreted as no
perceived handicap, and scores between 10-40 represent varying degrees of perceived handicap.

Hearing Profile: According to your responses to the questionnaire, your hearing handicap score
today was (insert score here). Research has shown that individuals with scores of 10 or greater are
likely to have measurable hearing impairment. Many people who are considering using hearing aids
for the first time lmve scores of 18 or greater, irrespective of severity of hearing loss. In addition,
34 weeks after these people have purchased hearing aids, their perception of hearing difficulties is
dramatically reduced. This outcome suggests that hearing aids have helped them in problematic
Situations.

Recommendations: It is recommended that you contact a local audiologist to arrange for a hearing
evaluation and possibly a trial period with hearing aids. Ifyou have any medical problems such as
pain or discharge from your ears, ringing or other sounds in your ears, or dizziness, you should
schedule an appointment with your primary-care physician.

Ifyou have any questions about this Hearing Handicap Inventory or its interpretation, please
contact:

(Insert name, title here)

(Insert address here)

(Insert phone number here)

Disclaimer: This has not been a direct test of your hearing. Recommendations and referral
information are based, in part, on a comparison of your questionnaire score with average scores
obtained from a sample of people having known hearing characteristics, and do not directly identify
hearing impairment or car pathology.

108

HEARING PROFILE:
HEARING HANDICAP INVENTORY
(Profile 6)

(IF the current score is 10 or more, AND a previous test result for this individual IS NOT found in
the database, AND the listening condition is Aided, print the following)

Examinee Name: Insert here

Examinee ID: Insert here

Listening Condition: Insert Unaided or Aided here
Date: Insert here

Time: Insert here

Interpretation: Scores indicate degree of hearing handicap; the higher the number, the greater the
perceived handicap associated with hearing impairment. The highest possible handicap score for a
given administration of the questionnaire is 40. Scores between 0-9 should be interpreted as no
perceived handicap, and scores between 10-40 represent varying degrees of perceived handicap.

Hearing Profile: According to your responses to the questionnaire, your hearing handicap score
today was (insert score here). This score suggests that you may have some residual disability
associated with your hearing loss, even though you wear hearing aids. Recent research has shown
that many people who are considering using hearing aids for the first time have scores of 18 or
greater, irrespective of severity of hearing loss.

Recommendations: If you are experiencing difiiculty with your hearing aid(s), such as whistling,
need for frequent repair, or poorer-than-expected performance, it is recommended that you contact
the professional who fitted your hearing aid(s). If you have any medical problems such as pain or
discharge from your ears, ringing or other sounds in your ears, or dizziness, you should schedule
an appointment with your primary-care physician.

If you have any questions about this Hearing Handicap Inventory or its interpretation, please
contact:

(Insert name, title here)

(Insert address here)

(Insert phone number here)

Disclaimer: This has not been a direct test of your hearing. Recommendations and referral
information are based, in part, on a comparison of your questionnaire score with average scores
obtained from a sample of people having known hearing characteristics, and do not directly identify
hearing impairment or car pathology.

109

HEARING PROFILE:
HEARING HANDICAP INVENTORY
(Profile 7)

(IF the current score is 10 or more, AND a previous test result for this individual IS found in the
database, AND the listening condition is Unaided, print the following)

Examinee Name: Insert here

Examinee ID: Insert here

Listening Condition: Insert Unaided or Aided here
Date: Insert here

Time: Insert here

Interpretation: Scores indicate degree of hearing handicap; the higher the number, the greater the
perceived handicap associated with hearing impairment. The highest possible handicap score for a
given administration of the questionnaire is 40. Scores between 0-9 should be interpreted as no
perceived handicap, and scores between 10-40 represent varying degrees of perceived handicap.

Hearing Profile: According to your responses to the questionnaire, your hearing handicap score
today was (insert score here). Research has shown that individuals with scores of 10 or greater are
likely to have measurable hearing impairment. Many people who are considering using hearing aids
for the first time have scores of 18 or greater, irrespective of severity of hearing loss. In addition,
34 weeks after these people have purchased hearing aids, their perception of hearing difficulties is
dramatically reduced. This outcome suggests that hearing aids have helped them in problematic
situations. Your previous score on (insert date of last test here) was (insert last test score here). A
difference in that score and today’s score of less than 10 suggests no real change in perceived
handicap, while a difference of 10 or more suggests a possible change in perceived hearing
handicap.

Recommendations: It is recommended that you contact a local audiologist to arrange for a trial
period with hearing aids. If you have any medical problems such as pain or discharge from your
ears, ringing or other sounds in your ears, or dizziness, you should schedule an appointment with
your primary-care physician.

If you have any questions about this Hearing Handicap Inventory or its interpretation, please
contact:

(Insert name, title here)

(Insert address here)

(Insert phone number here)

Disclaimer: This has not been a direct test of your hearing. Recommendations and referral
information are based, in part, on a comparison of your questionnaire score with average scores
obtained from a sample of people having known hearing characteristics, and do not directly identify
hearing impairment or ear pathology.

110

HEARING PROFILE:
HEARING HANDICAP INVENTORY
(Profile 8)

(IF the current score is 10 or more, AND a previous test result for this individual IS found in the
database, AND the listening condition is Aided, print the following)

Examinee Name: Insert here

Examinee ID: Insert here

Listening Condition: Insert Unaided or Aided here
Date: Insert here

Time: Insert here

Interpretation: Scores indicate degree of hearing handicap; the higher the number, the greater the
perceived handicap associated with hearing impairment. The highest possible handicap score for a
given administration of the questionnaire is 40. Scores between 0-9 should be interpreted as no
perceived handicap, and scores between 10-40 represent varying degrees of perceived handicap.

Hearing Profile: According to your responses to the questionnaire, your hearing handicap score
today was (insert score here). This score suggests that you may have some residual disability
associated with your hearing loss, even though you wear hearing aids. Recent research has shown
that many people who are considering using hearing aids for the first time have scores of 18 or
greater, irrespective of severity of hearing loss. Your previous score on (insert date of last test
here) was (insert last test score here). A difference in that score and today’s score of less than 10
suggests no real change in perceived handicap, while a difference of 10 or more suggests a possible
change in perceived hearing handicap.

Recommendations: If you are experiencing difliculty with your hearing aid(s), such as whistling,
need for frequent repair, or poorer-than-expected performance, it is recommended that you contact
the professional who fitted your hearing aid(s). If you have any medical problems such as pain or
discharge from your ears, ringing or other sounds in your ears, or dizziness, you should schedule
an appointment with your primary-care physician.

If you have any questions about this Hearing Handicap Inventory or its interpretation, please
contact:
(Insert name, title here)

(Insert address here)
(Insert phone number here)

Disclaimer: This has not been a direct test of your hearing. Recommendations and referral
information are based, in part, on a comparison of your questionnaire score with average scores
obtained from a sample of people having known hearing characteristics, and do not directly identify
hearing impairment or ear pathology.

111

Appendix H

First-Session Case History Form

112

First-Session Case History Form

Name: Date of Birth:

 

 

Please answer the following questions and send to the address at the bottom. You will
receive a phone call as soon as we receive this form to clarifir answers and/or to schedule
a date for you to come in to participate in the study.

1.

2.

9.

Do you think you have a hearing loss? Yes No (circle one)

Is so, was it gradual or sudden? Sudden Gradual

Do you notice any tinnitus (ringing or other sounds) in your ears? Yes No
Do you have a history of exposure to loud noises? Yes No

Do you have a history of ear infections? Yes No

Do you experience any dizziness or vertigo? Yes No

What medications are you currently taking?

 

What medications have you taken in the past for a prolonged period of time (one year
or more)?

 

Have you noticed any fluctuation in your hearing in the past six months? Yes No

10. Do you currently wear hearing aids? Yes No

11. If so, how ofien and for how long do you wear the hearing aids?

 

Thank you for your time. Please send this form to the following address:

Sara Shogren

Oyer Speech-Language-Hearing Clinic
Audiology and Speech Sciences
Michigan State University

East Lansing, Michigan 48824-1212

113

Appendix I

Second-Session Case History Form

114

Second-Session Case History Form

Name: Date of Birth:

 

 

Please answer the following questions.

1. Are you aware of a change in your hearing ability since the last test session?
Yes No (circle one)

2. Have you had a head injury since the last session? Yes N o
3. Do you notice any tinnitus (ringing or other sounds) in your ears? Yes No

4. Have there been any changes in your medications you are taking since the last session?
Yes No Ifyes, what?

 

kl't

. Do you experience any dizziness or vertigo? Yes No

.0‘

Have you been exposed to loud noise since the last session? Yes No

>1

If so, did you notice any tinnitus (ringing in your ears) after the noise exposure?
Yes No

00

. Have you noticed any fluctuation in your hearing since the last session? Yes No
9. Have you acquired a new hearing aid, or aids, since the last session? Yes No

10. If so, how often and for how long do you wear it/them?

 

11. Has there been any change in the performance of your hearing aid(s) since the last
session? Yes No

Thank you.

115

Appendix J

Exit Questionnaire—Long Program (LP/SP and SP/LP Sequences)

116

Exit Questionnaire—Long Program (LP/SP and SP/LP Sequences)

Name: Date of Birth:
Please answer the following questions by circling a number 1 - 5.
Number 1 = Strongly Disagree, Number 3 = Neutral, and Number 5 = Strongly Agree.

 

 

l. The Multimedia Hearing Handicap Inventory program was easy to use.
1 2 3 4 5

2. I found the section on use of the computer to be helpfirl.
1 2 3 4 5

3. 1 found the rephrasing of the questions helpfiil.
1 2 3 4 5

4. I found the illustrations of the questions helpful.
1 2 3 4 5

5. I learned some usefiil information about hearing loss from the program.
1 2 3 4 5

6. The voice was easy to hear.
1 2 3 4 5

7. The voice was easy to understand.
1 2 3 4 5

8. The text was easy to read.
1 2 3 4 5

9. The directions on how to use the program were easy to understand.
1 2 3 4 5

10. I learned some usefiil information about treatments for hearing loss.
1 2 3 4 5

11. The Hearing Profile given to me at the end of the program was easy to understand.
1 2 3 4 5

12. I will follow the suggestions given to me in the Hearing Profile.
1 2 3 4 5

117

13. What is the range of annual gross income in your household?
_ $0-$5,000
_ $5,000 - $15,000
_ $15,000 - $30,000
_ $30,000 - $50,000
_ $50,000 - $75,000
_ over $75,000

14. What is the highest educational level completed?
_ Did not complete high school
_ Completed high school (high school diploma)
_ Completed 1 or more years of college
_ Completed college (bachelor’s degree)
_ Master’s degree
_ Doctoral degree (Ph.D., Ed.D., etc.)
_ Professional degree (M.D., J.D., etc.)

Please rate how comfortable you are with the following equipment by circling a number.
Number 1 - Very Uncomfortable. Number 3 = Neutral, Number 5 = Very Comfortable.
Assume you are being asked to demonstrate your use of each.

1. Manual typewriter
1 2 3 4 5

2. Calculator
1 2 3 4 5

3. Adding Machine
1 2 3 4 5

4. Electric Typewriter
1 2 3 4 5

5. Computer (without a mouse)
1 2 3 4 5

.0‘

Computer (with a mouse)
1 2 3 4 5

Thank you for your time!

118

 

Appendix K

Exit Questionnaire—Short Program (SP/SP Sequence)

119

Exit Questionnaire—Short Program (SP/SP Sequence)

Name: Date of Birth:

 

 

Please answer the following questions by circling a number 1 - 5.
Number 1 = Strongly Disagree, Number 3 = Neutral, and Number 5 = Strongly Agree.

1. The Multimedia Hearing Handicap Inventory program was easy to use.
1 2 3 4 5

2. The voice was easy to hear.
I 2 3 4 5

3. The voice was easy to understand.
1 2 3 4 5

4. The text was easy to read.
1 2 3 4 5

{It

I found the rephrasing of the questions helpfiil.
l 2 3 4 5

6. I found the illustrations of the questions helpful.
1 2 3 4 5

7. The Hearing Profile given to me at the end of the program was easy to understand.
1 2 3 4 5

8. I will follow the suggestions given to me in the Hearing Profile.
1 2 3 4 5

9. What is the range of annual gross income in your household?

_ $0 - $5,000

__ $5,000 - $15,000
_ $15,000 -$30,000
_ $30,000 - $50,000
_ $50,000 - $75,000
__ over $75,000

120

10. What is the highest educational level completed?
_ Did not complete high school
_ Completed high school (high school diploma)
__ Completed 1 or more years of college
_ Completed college (bachelor’s degree)
_ Master’s degree
_ Doctoral degree (Ph.D., Ed.D., etc.)
_ Professional degree (M.D., J .D., etc.)

Please rate how comfortable you are with the following equipment by circling a number.
Number 1 = Very comfortable, Number 3 = Neutral, Number 5 = Very Comfortable.

Assume you are being asked to demonstrate your use of each.

1. Manual typewriter
1 2 3 4 5

2. Calculator
1 2 3 4 5

3. Adding Machine
1 2 3 4 5

4. Electric Typewriter
1 2 3 4 5

5. Computer (without a mouse)
1 2 3 4 5

6. Computer (with a mouse)
1 2 3 4 5

Thank you for your time!

121

REFERENCES

122

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