Cross-cultural adaptation of the Speech, Spatial and Qualities of Hearing Scale (SSQ) to Brazilian Portuguese

Abstracts

Purpose

To translate and culturally adapt the Speech, Spatial and Qualities of Hearing Scale (SSQ) for Brazilian Portuguese.

Methods

The processes of translation, back translation, evaluation by a committee of experts and cultural adaptation (pre-test) were performed. The cultural adaptation phase consisted of application of the questionnaire in 40 literate, non-hearing impaired, Brazilian adults. Two Portuguese versions of the SSQ were prepared: the first applied in Pilot Group 1 (20 subjects) and the second, after expert committee review, applied in Pilot Group 2 (20 subjects). Cultural equivalence of the questionnaire is reached when 85% of individuals have no difficulty understanding its questions. The internal consistency of the Portuguese SSQ was assessed using Cronbach's alpha.

Results

Comprehension difficulties were identified for question 14 of Part 2 and Question 5 of Part 3. The remaining questions were understood by more than 85% of the participants. The problematic questions were reviewed and modified without changing their context. The final version of the SSQ showed good cultural equivalence for Brazilian Portuguese, where 91.6% of participants reported ease of understanding of all questions. Statistical analysis revealed a high Cronbach's alpha coefficient (>0.8), confirming good internal consistency between the different items of the questionnaire.

Conclusion

The methodology employed was effective for producing the translation and verifying the cultural equivalence of the SSQ in Brazilian Portuguese.

Questionnaires; Translating; Hearing loss; Auditory perception; Hearing

Objetivo

Traduzir e adaptar, culturalmente, o questionário Speech, Spatial and Qualities of Hearing Scale (SSQ) para o Português Brasileiro.

Métodos

Foi realizada a tradução, retrotradução, avaliação por comitê de especialistas e adaptação cultural (pré-teste). A fase de adaptação cultural constou da aplicação do questionário em 40 brasileiros adultos, normo-ouvintes e alfabetizados em português. Foram elaboradas duas versões do SSQ em português, a primeira aplicada no Grupo Piloto 1 (20 sujeitos) e, após revisão do comitê de especialistas, uma segunda versão foi aplicada no Grupo Piloto 2 (20 sujeitos). Para haver equivalência cultural do questionário, é necessário que 85% dos indivíduos não apresentem dificuldades para compreender as questões. A consistência interna do SSQ, em português, foi verificada por meio do coeficiente alfa de Cronbach.

Resultados

Foi identificada dificuldade de compreensão na questão 14 da Parte 2 e na questão 5 da Parte 3. As demais questões foram compreendidas por mais de 85% dos participantes. As questões problemáticas foram revistas e modificadas, de forma a não alterar o contexto. Na aplicação da versão final do SSQ foi obtida uma boa equivalência cultural para o Português Brasileiro, já que 91,6% dos participantes relataram fácil entendimento de todas as questões. A análise estatística revelou alto coeficiente alpha de Cronbach (>0,8), demonstrando boa consistência interna entre os diversos itens do questionário.

Conclusão

A metodologia empregada foi eficaz para estabelecer a tradução e equivalência cultural do SSQ para o Português Brasileiro.

Questionários; Tradução; Perda auditiva; Percepção auditiva; Audição

INTRODUCTION

Hearing loss affects the communication process by making it harder for the individual to hear, listen to and understand speech. Reducing the limitations of hearing-impaired individuals in terms of understanding speech is the primary goal of auditory rehabilitation. Hearing aids, besides enhancing audibility, improve comprehension of speech sounds by processing the signal in environments that pose most difficulties for hearing, such as in the presence of competing noise.

The auditory system is responsible for detecting sounds, sensing intensity, discriminating sound patterns; perceiving distance, direction and location of the sound source, and for determining the quality of sounds. These features enable the use of hearing in the real world which includes alertness to sounds, monitoring the environment, recognizing and locating auditory events, monitoring and controlling one's own voice, appreciating auditory experiences, but primarily to understand the speech of others and communicate verbally in an effective manner. Thus, hearing and listening are integral elements of hearing assessment and rehabilitation for both understanding and communication.

Many audiologic studies dedicate scant attention to the complexities of human communication. Laboratory or clinical performance measures generally assess speech intelligibility based on recorded material of a single speaker with stable noise, whose spatial position, as well as spectral and temporal characteristics, are static and predictable(¹).

In real-life situations however, listeners must locate, identify, respond to and switch attention among different sound signals in order to maintain effective communication and attention to the sounds around them. Although sensoryneural hearing loss is typically cochlear in nature, the interaction between sensory and cognitive aspects of hearing have a substantial influence on how listeners function in everyday settings.

Test batteries used in audiologic assessment are effective for quantifying hearing loss, but their results do not reflect communication difficulties faced by hearing-impaired individuals in their daily lives. This calls for the use of other instruments that are easy to apply in routine clinical practice and can assess the limitations in hearing involving everyday situations and reflect individual perceptions of the communication difficulties caused by hearing loss.

With the goal of assessing abilities and experiences involving hearing in complex everyday listening situations Gatehouse and Noble(¹) developed the Speech, Spatial and Qualities of Hearing Scale (SSQ). This questionnaire covers a number of different domains, such as situations of directional hearing related to different distances and movement; discrimination of simultaneous sounds and voice flows; listening ability; naturalness and clarity of everyday sounds and of different musical pieces and instruments. Version 5.6 of the SSQ consists of 49 questions divided into three parts, with 14 questions related to hearing for speech sounds; 17 investigating different components of spatial hearing and 18 on the qualities of hearing.

The SSQ is one of few instruments designed to measure these aspects and has been widely used for assessing functional hearing loss and the benefits of different strategies for auditory rehabilitation(²-⁶). The scale is available in many languages including English, Danish, French, German, Polish, African, Spanish, Italian and Turkish(⁷-¹⁰), but not in Portuguese.

Therefore, the objective of the present study was to perform the translation and cultural adaptation of the Speech, Spatial and Qualities of Hearing Scale (SSQ) into Brazilian Portuguese.

METHODS

The present prospective clinical study with an exploratory and quantitative approach was approved by the Research Ethics Committee of the Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), n°273.023. The study was carried out at the Speech-Language and Hearing Clinic of the institution and involved individuals who agreed to undergo the procedures required to perform the study and signed the Free and Informed Consent Form.

The author of the original version was contacted and granted permission for the translation and validation of the questionnaire for use in the Brazilian population.

The SSQ questionnaire was translated using the methodology proposed by Guillemin et al.(¹¹) (1993) (Figure 1).

Figure 1
Process of translation and cultural adaptation to Brazilian Portuguese

In the first stage, two Brazilian speech-language and hearing specialists, fluent in English and aware of the purpose of the translation, separately translated the questionnaire. Subsequently, the two resultant translations were compared to identify any differences particularly with regard to semantic content, and changes made until a consensus was reached on a consolidated translated version.

In the second stage, a back-translation of the Portuguese translation into English was performed by a native speaker of English blinded to the original version and purpose of translating the questionnaire. A committee of specialists than checked the differences between the original English version, the first translation in Portuguese, and the back-translation into English. The committee reviewed the translations for semantic, idiomatic and conceptual equivalence, producing a Portuguese version of the questionnaire for application in the first pilot group. The analysis of semantic equivalence entailed assessment of the grammar and the vocabulary of the words in order to determine whether the meaning was retained and identify any difficulties in the translation. Idiomatic equivalence entailed checking for colloquialisms or idiomatic expressions that are hard to translate and in need of adaptation. For conceptual equivalence, semantic equivalence was checked taking into account different concepts associated with the cultures of each population.

The third stage (pre-test phase) was then carried out with application of the first translated version of the questionnaire in Portuguese.

The interview method reported in the literature(³) was employed to apply the SSQ questionnaire. The interviewer read out each question aloud and participants rated their communication performance on a scale of 0 to 10 for each situation presented. Participants were explained that on the scale of answers, 10 indicated perfect ability to perform the task described in the question, whereas 0 indicated inability to perform the situation assessed. In addition, there was an option "not applicable" for cases where the question did not portray an everyday situation.

During the application of the pre-test questionnaire, an additional question was included checking whether the respondent understood the question or not, based on a rating scale of understanding. According to the established criteria(¹¹), questions rated as hard to understand by more than 15% of interviewees required subsequent cultural adaptation.

Upon identification of comprehension difficulties for questions during the pre-test period, the committee of specialists met again to review and alter the questions, ensuring not to change their context. After incorporating changes, a revised version of the SSQ was produced in Portuguese and subsequently applied in another pilot group (Pilot Group 2) to guarantee cultural equivalence of all the questions.

A total of 40 individuals took part in the present study, selected based on the following inclusion criteria: age 18-50 years, normal-hearing, i.e. exhibit normal air-conducted auditory thresholds at frequencies of 500, 1000 and 2000 Hz up to 25 dBNA(¹²); Brazilian nationality and literate in Portuguese.

The first translated version of the SSQ questionnaire was applied to Pilot Group 1 comprising 20 individuals, five male and 15 female, with mean age of 38.8 years and mean schooling of 10.5 years.

After adaptation of the questions, the second version of the SSQ in Portuguese was applied to Pilot Group 2. A total of 20 adults, selected using the same eligibility criteria, were interviewed. This group comprised one male and 19 female, with mean age of 22.8 years and mean schooling of 13 years and three months.

Data analysis was performed using descriptive analysis and reliability was estimated by assessing internal consistency (Cronbach's Alpha - α). The Alpha coefficient measures the correlation between responses on a questionnaire by analyzing the profile of answers given by respondents. It constitutes a measure of correlation among questions. Given that items of a questionnaire use the same measurement scale, α coefficient is calculated based on the variance of its individual items and on variance in the sum of items for each rater. Internal consistency lies in the 0 to 1 range. Generally, α value of 0.6-0.7 indicates acceptable reliability while values >0.8 indicate good reliability.

RESULTS

The first 20 participants interviewed to assess understanding of the questionnaire in the pre-test phase – Pilot Group 1, had difficulty understanding question number 14 of Part 2 and question number 5 of Part 3. All remaining questions were understood by over 85% of participants (Chart 1).

Chart 1
Distribution of frequency and percentage understanding of questions from the SSQ questionnaire in Pilot Group 1

Part 1			Part 2			Part 3
Question	Frequency	Percentage	Question	Frequency	Percentage	Question	Frequency	Percentage
Q1	20	100%	Q1	20	100%	Q1	18	90%
Q2	18	90%	Q2	20	100%	Q2	19	95%
Q3	17	85%	Q3	20	100%	Q3	19	95%
Q4	20	100%	Q4	20	100%	Q4	20	100%
Q5	19	95%	Q5	20	100%	Q5	15	75%*
Q6	17	85%	Q6	20	100%	Q6	18	90%
Q7	20	100%	Q7	20	100%	Q7	20	100%
Q8	19	95%	Q8	17	85%	Q8	20	100%
Q9	20	100%	Q9	19	95%	Q9	20	100%
Q10	20	100%	Q10	18	90%	Q10	20	100%
Q11	19	95%	Q11	17	85%	Q11	18	90%
Q12	20	100%	Q12	20	100%	Q12	20	100%
Q13	20	100%	Q13	19	95%	Q13	20	100%
Q14	20	100%	Q14	11	55%*	Q14	18	90%
			Q15	18	90%	Q15	19	95%
			Q16	20	100%	Q16	19	95%
			Q17	17	85%	Q17	20	100%
			Q18	20	100%	Q18	20	100%

• * Issues whose understanding was less than 85% Note:SSQ = Speech, Spatial and Qualities of Hearing Scale; Part 1 = Hearing for speech; Part 2= Spatial hearing; Part 3 = Qualities of hearing

The two questions reassessed and revised by the committee of specialists were incorporated into the new version of the SSQ in Portuguese which was subsequently applied to Pilot Group 2. The changes made to the two questions proved effective, evidenced by the absence of major discordances and understanding of all the questions by 91.6% of interviewees (Chart 2). This version was therefore defined as final (^{Appendix 1}).

Chart 2
Distribution of frequency and percentage understanding of questions from the SSQ questionnaire in Pilot Group 2

Part 1			Part 2			Part 3
Question	Frequency	Percentage	Question	Frequency	Percentage	Question	Frequency	Percentage
Q1	20	100%	Q1	20	100%	Q1	20	100%
Q2	20	100%	Q2	20	100%	Q2	20	100%
Q3	20	100%	Q3	20	100%	Q3	20	100%
Q4	20	100%	Q4	20	100%	Q4	20	100%
Q5	20	100%	Q5	20	100%	Q5	20	100%
Q6	20	100%	Q6	20	100%	Q6	20	100%
Q7	20	100%	Q7	20	100%	Q7	20	100%
Q8	20	100%	Q8	20	100%	Q8	20	100%
Q9	20	100%	Q9	20	100%	Q9	20	100%
Q10	20	100%	Q10	20	100%	Q10	20	100%
Q11	20	100%	Q11	20	100%	Q11	20	100%
Q12	20	100%	Q12	20	100%	Q12	20	100%
Q13	20	100%	Q13	20	100%	Q13	20	100%
Q14	20	100%	Q14	19	91,6%	Q14	20	100%
			Q15	19	91,6%	Q15	20	100%
			Q16	19	91,6%	Q16	20	100%
			Q17	20	100%	Q17	20	100%
			Q18	20	100%	Q18	20	100%

• Note: SSQ = Speech, Spatial and Qualities of Hearing Scale; Part 1 = Hearing for speech; Part 2= Spatial hearing; Part 3 = Qualities of hearing

Means, standard deviations, along with minimum and maximum scores on the items of the SSQ in Portuguese, are given in Table 1. Mean scores on Part 1, Part 2 and Part 3 ranged from 5.8 to 9.4 points. Standard deviations ranged from 0.57 to 3.32, thus demonstrating sensitivity to variation and discriminative power among the individuals.

Table 1
Descriptive analysis for each question, on the three domains of the SSQ (Parts 1, 2 and 3)

	Question	Mean	SD	Minimum	Maximum
Part 1	Q1	7.8	2.32	2	10
	Q2	9.7	0.57	8	10
	Q3	9.0	1.48	5	10
	Q4	8.3	2.08	2	10
	Q5	7.9	2.48	0	10
	Q6	7.0	1.87	3	10
	Q7	8.6	1.34	6	10
	Q8	8.0	2.02	3	10
	Q9	8.4	1.78	3	10
	Q10	5.8	3.32	0	9
	Q11	7.9	2.10	3	10
	Q12	8.2	1.74	4	10
	Q13	9.7	0.57	8	10
	Q14	5.9	3.15	0	9
Part 2	Q1	8.0	2.05	1	10
	Q2	8.0	2.17	1	10
	Q3	9.1	2.14	1	10
	Q4	8.9	2.18	1	10
	Q5	7.7	2.12	1	10
	Q6	8.5	2.13	1	10
	Q7	8.2	2.19	1	10
	Q8	7.8	2.45	1	10
	Q9	8.1	1.98	1	10
	Q10	7.7	2.07	1	10
	Q11	8.3	2.29	1	10
	Q12	8.7	2.01	1	10
	Q13	8.7	2.02	1	10
	Q14	9.2	2.04	1	10
	Q15	6.8	2.54	1	10
	Q16	6.7	2.59	1	10
	Q17	7.9	2.25	1	10
Part 3	Q1	9.5	1.05	6	10
	Q2	8.8	1.49	6	10
	Q3	9.2	1.15	6	10
	Q4	9.1	1.25	6	10
	Q5	9.3	1.03	7	10
	Q6	9.6	0.81	7	10
	Q7	7.9	2.19	3	10
	Q8	9.4	0.94	7	10
	Q9	9.3	1.03	7	10
	Q10	9.4	1.14	5	10
	Q11	9.2	1.39	5	10
	Q12	9.0	2.08	1	10
	Q13	9.2	1.05	7	10
	Q14	7.9	2.35	0	10
	Q15	8.3	2.27	0	10
	Q16	8.3	2.35	3	10
	Q17	9.1	1.13	7	10
	Q18	8.3	2.03	1	10

• Note: SSQ = Speech, Spatial and Qualities of Hearing Scale; Part 1 = Hearing for speech; Part 2 = Spatial hearing; Part 3 = Qualities of hearing

The 49 items of the SSQ in Portuguese yielded a Cronbach´s Alpha of 0.94, indicating high internal consistency. The subscales (domains) also exhibited good reliability (Table 2).

Table 2
Internal consistency measurements by domain and total, on the SSQ questionnaire in Portuguese

SSQ	Number of items	Cronbach´s Alpha
Part 1	14	0.910
Part 2	17	0.977
Part 3	18	0.850
Total	49	0.946

• Note: SSQ = Speech, Spatial and Qualities of Hearing Scale; Part 1 = Hearing for speech; Part 2 = Spatial hearing; Part 3 = Qualities of hearing

DISCUSSION

The Speech, Spatial and Qualities of Hearing Scale (SSQ) is an important, subjective tool for assessing hearing. The scale comprises 49 questions related to hearing in everyday situations. The questions are divided into three parts: hearing for speech sounds, spatial hearing, and quality of hearing. The SSQ has been translated into many languages and used in clinical practice in numerous countries(²-⁴). However, the instrument had not been used in Brazil since no version in Brazilian Portuguese was available.

The methodology employed(¹¹) to perform the translation and cultural adaptation of the SSQ questionnaire has been previously used to translate other assessment instruments(¹³-¹⁵) and in all cases, including translation of the SSQ into Brazilian Portuguese, has proven effective.

The use of a more detailed systematic approach for the translation and cultural adaptation of a questionnaire was essential to allow difficulties in equivalence to be identified, proving a more effective method than simple translation and back-translation of the instrument. The present adaptation exhibited a highly satisfactory level of semantic equivalence between the version in Portuguese and the original in English. Few of the original items needed adapting and the whole scale was subjected to language analysis from a contextual perspective and also regarding the process of literal translation.

The Speech, Spatial and Qualities of Hearing Scale (SSQ) exhibited ease of understanding and clinical applicability as previously shown in the literature(²-⁴). The SSQ in Portuguese should contribute to the clinical assessment of hearing-impaired individuals and help in the planning of hearing rehabilitation and in assessing its results.

Internal consistency is a measure based on the correlation between different items contained in the same test (or between the same subscales in longer tests). The final Portuguese version of the SSQ had a high Cronbach's Alpha coefficient both on the assessment by domain and on the analysis of the three clustered groups of questions, i.e. the items on the SSQ questionnaire reliably assessed the same construct, the self-perceived performance of the individual in complex and dynamic listening environments such as hearing for speech, spatial hearing, and other qualities of hearing of the individual.

The Portuguese version of the SSQ met the criteria for conceptual equivalence, equivalence of its items, and semantic equivalence. However, in order to complete the process of adaption to the Brazilian culture, test-retest and external validation is necessary for wider use of the instrument. Since validation is a continuous process, future assessments should include larger samples involving different populations and settings. Further studies of the SSQ culturally adapted to Brazilian Portuguese should be carried out, analyzing its reliability and validating its use in Brazil with larger samples.

CONCLUSION

The procedure for translating the instrument into Portuguese, based on a standardized method, proved effective for establishing cultural equivalence in Brazilian Portuguese. A version of the Speech, Spatial and Qualities of Hearing Scale (SSQ) questionnaire in Brazilian Portuguese was produced and is currently undergoing validation.

Appendix 1 Speech Spatial Qualities of Hearing Scale (SSQ) – translated and adapted version

Orientações sobre como responder as perguntas

As seguintes questões abordam aspectos da sua capacidade e experiência de ouvir e escutar em diferentes situações.

Para cada questão, assinale um (X), em qualquer local da escala apresentada, que varia de 0 a 10. Marcar um (X) no 10 significa que você seria perfeitamente capaz de fazer ou experimentar o que está descrito na questão. Marcar um (X) no 0 significa que você seria incapaz de fazer ou experimentar o que está descrito.

Como exemplo, a questão 1 pergunta sobre ter uma conversa com alguém enquanto a televisão está ligada. Se você é perfeitamente capaz de fazê-lo, então deve assinalar o final da escala à direita. Se você poderia acompanhar cerca de metade da conversa nessa situação, deve marcar no ponto médio da escala e assim por diante.

Esperamos que todas as questões sejam relevantes à sua experiência cotidiana, mas se uma questão descreve uma situação que não se aplica a você, assinale um (X) em "não se aplica". Por favor, também escreva uma observação ao lado da questão explicando porque isso não se aplica ao seu caso.

Por favor, responda às seguintes questões e então prossiga com o questionário sobre a sua audição.

Nome:

Data:

Idade:

Assinale uma das seguintes opções:

⃞ Eu não tenho próteses auditivas

⃞ Eu uso uma prótese auditiva (OE)

⃞ Eu uso uma prótese auditiva (OD)

⃞ Eu uso duas próteses auditivas (ambas as orelhas)

Se você usa próteses auditivas, há quanto tempo faz isso?

______ anos

______ meses

ou

______ semanas

Se você tem duas próteses auditivas e as tem usado por períodos de tempo diferentes, por favor, anote a informação sobre cada uma delas.

REFERÊNCIAS

• ¹
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• ²
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• ³
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• ⁴
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  Ferreira PEA, Cunha F, Onishi ET, Branco-Barreiro FC, Ganança FF.Tinnitus handicap inventory: adaptação cultural para o Português Brasileiro. Pró-Fono. 2015;17(3):303-10. doi:10.1590/S0104-5687200500030000
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  Nigri PZ, Peccin MS, Almeida GJM, Cohen M. Tradução, validação e adaptação cultural da escala de atividade de vida diária. Acta Ortop Bras. 2007;15(2):101-4. doi:10.1590/S1413-78522007000200009
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  Michels MJ, Coral MHC, Sakae TM, Damas TB, Furlanetto LM. Questionário de atividades de autocuidado com o diabetes: tradução, adaptação e avaliação das propriedades psicométricas. Arq Bras Endocrinol Metabol. 2010;54(7):644-51. 10.1590/S0004-27302010000700009
  » https://doi.org/10.1590/S0004-27302010000700009

• Study conducted at School of Speech-Language Pathology and Audiology, Faculdade de Ciências Médicas da Santa Casa de São Paulo – FCMSCSP – São Paulo (SP), Brazil.

Publication Dates

• Publication in this collection
  Jul-Sep 2015

History

• Received
  7 May 2015
• Accepted
  10 Aug 2015