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Recent interest has surfaced in symptom-specific handicap outcome measures for many audiological and otological diseases. There is no valid and reliable tinnitus handicap inventory for Turkish people in their native language.
We assessed test-retest reliability with a second investigation in 21 randomly chosen patients. The three groups of patients were divided according to their ages: 19-39 years, 40-59 years, and 60 years and older. We tested internal validity by multi-item analysis, to assess item convergent and discriminant validity. This study was designed to obtain the THI as a standard measuring instrument for patients and clinicians all over Turkey.
How to cite this article Mahmoudian S, Shahmiri E, Rouzbahani M, Jafari Z, Keyhani MR, Rahimi F, Mahmoudian G, et al. Tinnitus is a debilitating condition that is widespread yet difficult to successfully diagnose and treat. Regarding to McFadden (1982), Tinnitus is the "conscious experience of a sound that originates in an involuntary manner in the head of its owner or may appear to him to be so"1. Some underlying causes were defined for tinnitus, including otological diseases, tumors, ototoxicity, acoustic trauma, noise-induced and psychological disturbances. Since almost the majority of tinnitus questionnaires for assessing individual's reaction to tinnitus are in English language and there is still no standardized and valid questionnaire in Persian, the provision of a Persian version of these questionnaires according to the culture of Iranian society is inevitable. The first aim of the current study was to investigate the linguistic validity of the Persian Version of the THI as a measure of tinnitus-related reactions in three dimensions 95 International Tinnitus Journal, Vol. The present study consists of translation and standardization of the original version of THI [25] into Persian version (Linguistic validation) then the reliability of the Persian version of THI has been identified. In the first step according to the IQOLA protocol26, THI questionnaire was translated by two native speakers of Persian, bilingual in English and Persian, separately translated the original instrument into Farsi (Persian) language (translator 1 and 2). At the second step of linguistic validation, we used two other translators (5 and 6) with high level of proficiency in Persian and English languages. Before the THI-P can be administered to assess the effects of tinnitus, its test-retest stability must be determined. The degree of hearing loss is defined as the severity of the hearing loss measured by audiometry.
Patients were asked to complete the THI-P questionnaire as part of the initial assessment at the tinnitus center. All analyses were performed using statistical package for social science (SPSS) version 16.
Student t-test was used to test for differences between THI scores and its subscales and gender, hearing impairments and tinnitus laterality.
From the 25 items of THI-US version translated to Persian version of THI, thirteen items (52%) including 2, 3, 7, 8, 9, 10, 11, 15, 16, 20, 21 and 22 as an easy translation, six items (24%) including 6, 12, 14, 17, 18 and 19 as a relatively easy translation and finally other six items including 4, 5, 13, 23, 24 and 25 as a difficult translation were evaluated by translators.
The tinnitus characteristics of the 112 subjects attending the tinnitus center to consult about tinnitus management have been summarized in Table 1.
The frequency distribution of tinnitus subjects who answered the various items in the THI-P questionnaire has been outlined in Table 3.
The correlation of age and total THI-P score was calculated by Pearson's product and for calculating the effect of sex and total THI-P score we applied independent student t-test. Pearson product-moment correlations were calculated between the first and second administrations of the THI-P among the tinnitus subjects to assess the strength of the relationship between tests and retest (Figure 2).
We assessed the percentages of "Yes", "Sometimes" and "No" answers and then we calculated the reproducibility (internal consistency reliability) of items in THI-P using the Cronbach's-alpha coefficient. In recent years, the need to assess and consider the consequences of diseases as well as distressing symptoms has been specifically considered in all special facilities of medical and rehabilitation. Hence, as a first step, standardization and validation of appropriate tools such as psychometric questionnaires are very important in order to evaluate disease or monitor treatment outcomes. One of our ultimate goals for validating the Persian version of THI and for conducting current study was to develop a standard self-report tinnitus instrument, appropriate to the Persian's culture so that it could be administered as a criterion measure in clinical and research approaches available to clinicians and other researchers who are involved in different aspects of tinnitus subjects.
It is widely agreed that in addition to desirable translation to validate an assessment tool, we should also use the terms adapted for socio-cultural setting of the population which will serve. The translation quality was assessed by translator 3 and 4 using a VAS criterion (from desirable up to absolute undesirable score). In order to determine the divergent or discriminate validity of THI-P, we used the effects of three factors including hearing impairment, gender and age of the tinnitus subjects on the questionnaire scores.
Regarding to other studies, in order to identify validity of THI questionnaires (German, Brazilian, Danish versions), authors administered the correlation between items in translated THI with the other standardized questionnaires (convergent validity structure)33. The most important specifications of one assessing instrument are always including repeatability, consistency and validity of obtained scores. The other part of consistency was related to the correlation between test-retest which was evaluated by Pearson correlation coefficient. In this study, with omitting any of the THI-P items, the acquired score of Cronbach's alpha coefficient as calculated by the total score of Cronbach's alpha coefficient was very close (r = 0.943). In conclusion, this study demonstrated that the Persian version of THI (THI-P) is a valid and reproducible tool to assess the psychological complaints of tinnitus sufferers. We find that THI-P in structural and practical point of view is compatible with the original English version of THI. In this era, the determination of both objective and subjective effects of clinical intervention is critical, because clinicians using outcome measures could make decision about patient's status and the effective treatment. OBJECTIVE: To determine the validity and reliability of a Filipino translation of the Tinnitus Handicap Inventory (THI), a self-report measure of tinnitus handicap. CONCLUSION: The results of the present study suggest that the THI-PH is a valid and reliable tool that can be used to quantify the effects of tinnitus on the quality of life of Filipino tinnitus patients. A review of the audiology request forms at the Ear Unit of the Philippine General Hospital from January to July 2009 revealed that out of 1079 patients that underwent audiometry testing, 348 complained of tinnitus - 207 of which as a symptom secondary to another problem, and 141 as a chief complaint. Depending on its severity, tinnitus can have serious effects on a patient's quality of life. There are a number of questionnaires available to measure the effects of tinnitus on quality of life. Since there are currently no available tinnitus-specific questionnaires in Filipino and there are currently no available data on the effects of tinnitus on the quality of life of Filipino tinnitus patients, there is a need for a valid tinnitus questionnaire in the language. A Filipino tinnitus questionnaire will help quantify the effects of tinnitus on the quality of life of Filipino tinnitus patients, assist clinicians in justifying their decision for tinnitus therapy or in making the appropriate referrals, and can be used to objectively classify tinnitus patients into the three categories described by Tyler et al. The THI by Newman is psychometrically robust, easy to administer and interpret, and broad in scope. Each question can be answered by a "yes" which is given four points, a "sometimes" which is given two points, or a "no" which is given zero points. The final version of the Filipino THI was administered to 75 patients, 38 females and 37 males, ages 18 - 82 (mean age = 47.6) recruited consecutively at the Ear Unit of the Philippine General Hospital from February to mid-March 2010 after being assessed at the ENT-OPD.
Tinnitus pitch and loudness matches were determined using the two-alternative forced-choice method described by Vernon24. The original version of the THI (THI-US) was first translated into Filipino by three native speakers of Filipino bilingual in English.
The final THI-PH was then given to 75 tinnitus patients referred at the Ear Unit of PGH for audiologic testing after assessment at the ENT-OPD of PGH. Cronbach's alpha for the THI-PH total and its subscales compared to the THI-US and its subscales are given in Table 3. A majority of the subjects (46 per cent) were 46-65 years old followed by those in the 26-45 year-old age range (33 per cent), those in the 65 years and older followed (11 per cent), while the lowest concentration of subjects was found in the 18-25 year-old age range (9 per cent). A majority of the subjects (68 per cent) suffered from chronic tinnitus (tinnitus for more than six months).
In terms of tinnitus sounds reported, a majority of the patients claimed that their tinnitus was either insect-like or wind-like. Tinnitus pitch was most frequently matched at 2,000 Hertz while loudness was most frequently matched at 0-10 decibels sensation level. A non-significant correlation was found between the duration of the tinnitus and tinnitus handicap scores (p-value = 0.34).
In terms of age, across all tinnitus handicap grades, most of the cases affected were in the 46-65 year-old age range except for the severe grade where a majority of the cases were in the 26-45 year-old age range (Table 2).
For the tinnitus sounds reported in relation to tinnitus handicap, in the moderate level, a majority of the patients reported their tinnitus to be insect-like while in the severe level they reported it to be wind-like.
For the pitch and loudness matches, in the mild and catastrophic grades, pitch was mostly matched at 2,000 Hertz while in the severe grade, pitch was most frequently matched at 1,000 Hertz (Figure 1). Table 4 shows that the results obtained are similar to the original version and also to other language validations. The slightly poorer internal consistency reliability for the Catastrophic subscale is attributed to the shorter number of items in that scale.
Findings in terms of the prevalence of tinnitus as a function of age are similar to the findings of Hinchcliffe (1961)26,who concluded that tinnitus was most prevalent in the 55-64 year old age range and was least prevalent in the 18-24 year old age range.
Tinnitus being more frequently experienced in the left ear compared to the right was previously reported by Axelsson and Ringdahl (1989)27, Hazell (1981)28 and Coles (1984)29.
Since the design of this study did not allow for the testing of the questionnaire's repeatability, it is recommended that the THI-PH be tested on another set of patients. It would also be interesting to investigate the relationship between the THI-PH and psychopathological problems for the subset of patients with catastrophic tinnitus. In conclusion, the results of the study suggest that the THI-PH is a valid and reliable tool that can be used on Filipino patients to quantify the effects of tinnitus on daily living and to test the efficacy of tinnitus treatments.
Paper submitted to the RBCMS-SGP (Publishing Management System) on July 2, 2012; and accepted on August 16, 2012. Each of two individuals independently translated and retranslated the English version of the THI, and it was adapted by an expert team. That is, clinicians plan to quantify their patients' symptoms, administer their treatment, and get objective results about the patient's satisfaction. Therefore, most clinicians use their own questionnaires, which lack reliability or validity (or both). This study sought to analyze the validity and reliability of the Turkish version of the THI.
Internal consistency reliability of the Turkish version of the THI was assessed using Cronbach's alpha.
This was assessed by categorizing the patients into three groups according to their age and according to tinnitus duration.
We investigated the differences in the mean values for scale and subscales, though the F test results did not provide significant results. The 25-item inventory can be used in neurootology clinics to evaluate the tinnitus symptom and its impact on knowledge and attitudes toward tinnitus. After minor alterations in translation and retranslation, scaling assumptions were met satisfactorily for the three multi-item subscales, and the first Turkish-language scale for evaluating tinnitus was developed.
Persian language version of the "Tinnitus Handicap Inventory": translation, standardization, validity and reliability.
This symptom is a debilitating condition that is widespread yet difficult to successfully diagnose and treat.
For some patients with tinnitus this sensation does not interfere with their daily activities and for others it is disabling and restricts their work, sleep, and social activities10,11. Numerous studies using various open-ended or self-report structured questionnaires have been conducted.
For this reason we perform according to the International Quality of Life Assessment protocol (IQOLA) approved by WHO in 1991.
Craig Newman, author of the original questionnaire of THI, has permitted us to develop and use the Tinnitus Handicap Inventory in Persian Language Version.
They were asked, if needed, to mention a list of possible translations for some words, sentences and phrases. On the other hand, the words and items on the level of reading ability of 14 years old or less were noticed for linguistic validation of THI-P. All subjects gave written informed consent in accord with the declaration of Helsinki before examinations. So, in retest after one week from filling the first THI-P, the questionnaire was filled again by the same patients. Descriptive statistics, including frequency distributions, means and standard deviation were computed for each item of THI-P. Multiple linear regression analysis was used to study the effect of gender, hearing loss and the tinnitus laterality on the overall THI score as well as the functional, emotional and catastrophic subscales. In this study, the research method and the role of subjects were explained clearly and completely.

The translation clarity exception in one item (item 17) which was evaluated as relatively desirable, in the other 24 items (96%) of THI-P was evaluated as desirable. Most of tinnitus subjects (72.7%) perceived one type of tinnitus sound, while others complained of sensation of more than one type of sound on different occasions. Scatter plots illustration the relationship between the THI-P score and the age in all subscales. As shown in Figure 2, the scatter plot indicates the correlation between the first (test) and second (retest) administration of the THI-P and their subscales on tinnitus subjects.
Scatter plots illustration the correlation between the first (test) and second (retest) administration of the THI-P and their subscales. Researches in many different countries around the world in this area indicate the global emphasis on the importance of these assessments. This symptom is as a common problem which can affect several aspects of patients' life including: going to sleep, understanding speech, depression, irritation, concentration and worse on awakening.
To acquire this expressed goal, it was necessary to translate and standardize the original version of THI and then to evaluate the test-retest reliability of the THI-P.
The measure of difficulty of Persian translation of THI was evaluated by translator 1 and 2 using a visual analogue scale from easy up to difficult (VAS; 100 mm total length). The measure of this criterion administers three measures including clarity scores, common language and identifies conceptual equivalence. Both convergent and discriminate validity methods were used for identifying validity of original English version of THI19. In current research the reliability of THI-P was evaluated from two 102 International Tinnitus Journal, Vol.
We obtained 0.96 in Persian THI version, consistent with significant correlation in retest.
The findings showed that none of the items of the Persian version of the questionnaire need to be removed.
Also, THI-P could be administered as a standard measuring instrument for patients and clinicians all over Iran. Henceforth, THI-P could be used for both clinical and research purposes by different professionals like audiologists, otolaryngologists, psychiatrists and could be also used for monitoring, treatment and rehabilitative effects on the life's quality of tinnitus sufferers.
ENT and Head & Neck Research Center, Hazrat Rasoul Akram Hospital, Tehran University of Medical Sciences (TUMS), Tehran, Iran. Department of Audiology, School of Rehabilitation Sciences, Tehran University of Medical Sciences (TUMS). Department of Biometry, School of Rehabilitation Sciences, Tehran University of Medical Sciences (TUMS). In the United States alone, the American Tinnitus Association estimates that around 40 million Americans experience tinnitus regularly, 10 million seek medical attention for it, and close to two million find their tinnitus to be debilitating1.
There have been a few studies on the efficacy of medications in the treatment of tinnitus, but none on the local prevalence and incidence of tinnitus. One is the Tinnitus Reaction Questionnaire which aims to describe the psychological distress associated with tinnitus7.
It is widely used in clinical practice abroad and would serve as an effective tool to use in the local setting16. The total score could range from zero, indicating no tinnitus handicap, to 100 indicating the worst annoyance from tinnitus possible. If the tinnitus was equally loud in both sides, the ear with the better hearing was the test ear. The three translations were then combined and the final version was back-translated into English by an English speaker who was unfamiliar with the THI-US. The THI-PH's Cronbach's alpha for the total scale is only slightly lower than the original version. In the majority of cases (77 per cent) the audiograms revealed bilateral sloping high-frequency hearing losses. In 52 per cent of the cases (39 patients), tinnitus was reported as a secondary symptom, while the remaining 48 per cent (36 patients) cited tinnitus as a chief complaint. A majority of the cases were moderate (31 per cent), followed by mild (24 per cent), slight and severe (16 per cent each), and catastrophic (13 per cent). In the catastrophic level, a majority of the patients reported their tinnitus to be similar to a whistling sound.
Almost all loudness matches across all handicap grades were at 0-10 decibels sensation level (SL) except for the severe grade where the loudness was most commonly matched at 11-20 dB SL (Figure 2).
They postulated that this could be due to a number of factors including handedness and asymmetrical noise exposure.
Philippine National Ear Institute, National Institutes of Health - University of the Philippines - Manila - AC - Philippines.
Department of Otorhinolaryngology, College of Medicine and Philippine General Hospital - University of the Philippines - Manila - Philippines.
The Tinnitus Handicap-Support Questionnaire [1,7], the Tinnitus Effect Questionnaire [8], and the Tinnitus Severity Questionnaire [9] are measurement tools in the English literature, but they have no (or low) internal consistency reliability and low test-retest reliability. One translator was aware of the purpose of the study and the concepts involved in the instrument: to obtain a better idiomatic and conceptual-rather than literal-equivalence between the two versions of the inventory and to render the intended measurement more reliable. We made an inspection of the percentage of subjects responding "yes," "sometimes," or "no" to individual questions. Total scale scores, Pearson's correlation coefficients (r), and ICCs for three subscales are shown in Table 7.
Patients with tinnitus generally live with their problem for long periods of time; thus, they want to know their symptom's quality or intensity. On the basis of our study results, we found the first Turkish version of the THI to be a measure that is acceptable, reliable, and valid for evaluating tinnitus in patients. The Hearing Handicap Inventory for Adults: Psychometric adequacy and audiometric correlates.
Functional status and well-being of patients with chronic conditions: Results from the Medical Outcomes Study. Brazilian- Portuguese validation of the University of Washington Quality of Life Questionnaire for patients with head and neck cancer. In JM Aran, R Dauman (eds), Tinnitus 91: Proceedings of the Fourth International Tinnitus Seminar.
Objectives: The aim of current study was to compose and validate a Persian version of the Tinnitus Handicap Inventory (THI-P). The prevalence of chronic tinnitus in the general population is estimated between 5-15% and causes to develop serious psychosocial complications in 1% to 3%1. It is reported that tinnitus can be severe enough to cause significant discomfort in one's daily life12. Finding the effects of tinnitus on the quality of life and assessing the individual's reaction to tinnitus are very important. The aim of IQOLA is to translate and provide health questionnaires with high validity and reliability for using in different countries by their formal language26.
This version is both simple to administer and interpret and also a powerful psychometric tool. After that, each of the expert translators were asked about the difficulties of the translations and they were attributed a score according to the 100 point visual analogue scale (VAS). Afterward, the pooled back translation was compared and formed by translators and then an agreement was obtained for one English version of THI questionnaire for finding the coherency with original version. Therefore the formulated initial Persian version of the instrument was attended by 24 (10 female and 14 male) high school students in Tehran. The Cronbach's Coefficient Alpha test (where values>0.70 indicate a satisfactory internal consistency) was used to test for the evaluating internal stability of the THI-P29, and Pearson correlation coefficient was calculated between the total score of the THI-P and the scores of its subscales, age and pure tone average (PTA). The common language score of THI-P was assessed as desirable in all 25 items (100%) and also the conceptual equivalence for three items (4, 10, 16) undesirable response (12%), for two items (23 and 14) in a relatively desirable level (8%), and the other items were desirable response (80%). The type of sound reported by most tinnitus subjects was subjectively described as high-pitch tone, matched by external stimuli (described by 52.3% of subjects). Table 2 summarized the mean air conduction thresholds across frequencies of 500-4000 Hz for left and right ears.
As shown in Figure 1, the total score of THI-P and its subscales were not correlated with the age of tinnitus subjects.
Total score of the THI-P and its associated subscales are very close to corresponding values in the original THI-US (Table 6). In Iran, in order to converge and coordinate with the ongoing research at the international level concerning the evaluation of consequences of diseases, impairments, handicaps, treatments and rehabilitation, we should create a new movement.
Sense of the various problems among the subject sufferer from tinnitus and understanding the impact of tinnitus on their quality of life are of the uttermost importance. Translation of the original questionnaire of THI in Persian language in overall was easy due to its simple sentences, whereas, the translators in six items acknowledged difficult translation (items of 4, 5, 13, 23, 24 and 25). The translation clarity in 24 items of THI-P was evaluated desirable and only one item (item 17) evaluated as relatively desirable. Majority of epidemiological tinnitus studies have reported a positive relationship between tinnitus and hearing loss4,34-35.
This valid tool allows us to quantify how much tinnitus impacts the life's quality of these individuals. Functional brain abnormalities localized in 55 chronic tinnitus patients: fusion of SPECT coincidence imaging and MRI. Prevalence of tinnitus and hearing thresholds of a non-noise-exposed population with and without tinnitus. Assessment of psychopathological aspects and psychiatric comorbidities in patients affected by tinnitus.
Psychologic profile of tinnitus patients using the SCL-90-R and tinnitus handicap inventory. Psychological profile and somatic complaints between help-seeking and non-help-seeking tinnitus subjects. Tinnitus reaction questionnaire: psychometric properties of a measure of distress associated with tinnitus.
Developmental and Psychometric Adequacy of the Screening Version of the Tinnitus Handicap Inventory. Psychometric Adequacy of the Tinnitus Handicap Inventory (THI) for Evaluating Treatment Outcome. Tinnitus with normal hearing sensitivity: extended high-frequency audiometry and auditory nerve brain-stem-evoked responses. Validity of the Italian adaptation of the Tinnitus Handicap Inventory; focus on quality of life and psychological distress in tinnitus-sufferers. Brazilian Portuguese Language version of the "Tinnitus Handicap Inventory": Validity and Reproducibility. Impact of tinnitus as measured by the Tinnitus Handicap Inventory among tinnitus sufferers in Singapore. The Catastrophic subscale showed poorer internal consistency reliability (Cronbach's alpha = 0.63) due to the shorter number of items in that scale. Out of the 1,756 reviewed patient records, they discovered that tinnitus was the third most common pretest diagnosis, comprising 9.3 per cent2. Another is the Tinnitus Problem Questionnaire for determining the different health, hearing, sleep, psychological, and situational difficulties associated with tinnitus13. A valid and reliable Filipino translation of the THI will help assess the effects of tinnitus on non-English speaking Filipinos and those with poor English skills.
A pair of tones was presented and the subject was asked to identify which tone best matches the pitch of their tinnitus. After comparing the THI-US and the back translation for coherence and making the appropriate revisions, the THI-PH and a tinnitus information sheet (Appendix B) were given to patients. The reliability coefficients of the THI-PH subscales are also comparable to the original THI-US.
In males, a majority of the cases were concentrated in the Moderate and Severe grades while in females most of the cases were either Moderate or Mild (Table 1).
This problem could be resolved by adding items to the catastrophic subscale to increase the alpha. Tyler (2000) stated that the relationship between these factors and the left-sidedness of the tinnitus was eventually proven to be insignificant.
As stated by Monzani, et al., this adds to the general, cross-cultural validity of the tool as a measure of perceived tinnitus handicap17. Tinnitus Reaction Questionnaire: Psychometric properties of a measure of distress associated with tinnitus. Tinnitus Annoyance and Difficulty in Activities of Daily Life Evaluated by the Tinnitus Handicap Inventory.

Brazilian Portuguese Language Version of the Tinnitus Handicap Inventory: Validity and Reproducibility. Validity of the Italian Adaptation of the Tinnitus Handicap Inventory; focus on quality of life and psychological distress in tinnitus patients.
Prevalence of the commoner ear, nose, and throat conditions in the adult rural population of Great Britain.
We assessed the internal consistency and reliability of the Turkish version by Cronbach's alpha. Additionally, these evaluations quantify the effects of tinnitus on functional, emotional, and social life. The original Tinnitus Handicap Inventory (THI), developed by a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, consists of 50 questions [10].
The other translator was unaware of the translation objective, and this was useful in eliciting unexpected meanings from the original tool. We assessed internal consistency coefficients (ICCs) for all three subscales: emotional, catastrophic, and functional. Item 21 had the greatest contribution-the emotional subscale-because of its highest item-total correlation score. This preliminary version of the THI is able to detect the quality of the tinnitus symptom and its impact on patients' daily lives and psychosocial functioning, in addition to registering satisfaction with treatment. Materials and Methods: The linguistic validation of the original version of THI into Persian version (THI-P) included translation, back translation and data gathering. Epidemiological studies indicated that in developed countries such as Germany about 1.5 million people, in the United States about 10 million out of 40 million tinnitus sufferers and a similar ratio in the United Kingdom have been reported that were seriously affected by tinnitus2-4.
Tinnitus symptoms have been linked to various psychological and psychosomatic disorders13-15. One of the most important methods in the assessment of the severity of tinnitus and its effects on the lifestyle of a patient is the use of psychometrical evaluations.
Finally, we formulated the initial Persian version of the instrument with proper and satisfactory translation. The final version of THI-P was administered in all tinnitus subjects who were managed in our center between September 2009 and May 2010. The score of "Yes", "No" and "Occasionally" were 4, 0 and 2, respectively in three subscales: emotional, functional and catastrophic. All personal information in the questionnaire were confidential and only used in this research.
The other descriptions of tinnitus included cricket, sizzling, hissing, humming and other sounds. Tinnitus is a subjective idiopathic symptom in which it is not detected by blood examination and CT scan or like this. In this regard, translator 1 and 2 were asked to provide a list of possible alternative translations for the replacement in relatively difficult and difficult items of THI-P. The prevalence of tinnitus among normal hearing subjects has been reported between 7%-10%36-37. Tyler and Baker (1983) found that tinnitus is associated with numerous complaints including irritability, depression, inability to relax and sleep, and concentration problems4. As of 2010, the Philippine Overseas Employment Administration estimated the number of Filipinos working abroad to be around 9.5-12 million as of 201022. It is composed of three subscales, namely, the functional subscale with 12 items to address role and physical functioning, the emotional subscale with eight items to address psychological distress, and the catastrophic response subscale with five items to address desperation and loss of control9. The patients were asked for feedback on the questionnaire and the appropriate revisions were then made. Those who refused to participate or opted to discontinue their participation were excluded from the study.
He suggested that more detailed research studies be done to investigate the concept of left versus right ear differences30. Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999, Clin Otolaryngol. Because the items having high item-total correlation were considered more representative of the scale's content, all itemtotal statistics were reported and are shown in Table 4. It is shown that 48% to 60% of patients with chronic or disabling tinnitus have major depressive disorder (MDD)16. Such self-report questionnaires include the Tinnitus Questionnaire (TQ)18, Tinnitus Handicap Inventory (THI)19, Tinnitus Severity Scale (TSS)20, Tinnitus Handicap Questionnaire (THQ)21, Subjective Tinnitus Severity Scale22 and Tinnitus Reaction Questionnaire (TRQ)23.
The THI is a 25-item self-report instrument which is divided into three subscales including functional, emotional and catastrophic reactions to tinnitus.
On the basis of these two translations and their VAS scores to each THI items, we formed the pooled version that was then reviewed by presence of translators for considering suggested replacing words and difficulty in translation.
This questionnaire was used as an initial instrument for gathering data from tinnitus subjects at next steps.
Each single item was read loudly and the participants were asked to follow the items on the given sheet. Age, gender, medical history and tinnitus characteristics were recorded as baseline information. In total, more than 92% of tinnitus subjects who attended the current study revealed high pitch tinnitus, matched by external stimuli (>3000 Hz). Independent Student t-tests did not demonstrate statistically difference between total THI-P score and those with or without hearing impairment, neither did those with unilateral or bilateral tinnitus (Table 4).
The main problem with tinnitus is its subjective nature so that evaluation of this complaint always depends upon patient's words. These alternative items were reviewed again by translator 3 and 4 in order to optimize quality of translation and finally revised for appropriate items.
In conceptual equivalence of the translation, three items had undesirable response (4, 10 and 16) and two items had relatively desirable response.
A validated THI in Filipino can also be used by these Filipinos abroad who prefer to answer questionnaires in their native language.
We assessed construct validity by analyzing the patients according to their age and to tinnitus duration. These findings indicate that the Turkish version of the THI has good stability in the test-retest trial to assess the clinical change.
In addition, tinnitus is a common symptom of the auditory system disorders that is usually associated with sensoryneural hearing loss6,7. Asplund reported that among subjects with tinnitus poor sleep and frequent waking were more common in men and women17. In this regard the client was questioned in order to find out which activity or performance of the patient is affected by tinnitus. Analysis of the THI items suggested that this self-report instrument had excellent internal consistency reliability and adequate convergent and constructive validity28.
It is worth to mention that in this step, for differentiation of the level of difficulty in translation, average scores less than 25 were considered as easy, more than 30 as difficult and between 25 and 30 as relatively easy.
Thus, items with undesirable translation were revised by translator 5 and 6 and revised by suggested replacing proper words, sentences and phrases.
As reported in several studies for the original version (US), Italian, Turkish, Danish, Portuguese and Singapore translations of THI19,28,38-41, the Persian version of THI was not significantly different in the handicap scores between those with normal hearing and those with hearing impairment with regard to the degree of handicap severity.
Eventually it became clear that internal consistency was high and the response of every item to the response of total items was matched. Two (3 per cent) showed a unilateral mixed hearing loss and seven patients had bilateral conductive hearing losses. Internal validity was tested by multi-item analysis, to assess item convergence and discriminant validity. The THI, beta version, is the most standardized tinnitus handicap- measuring tool in the literature (Table 1).
One of them was a medical doctor, and the other was a chiropractor; however, both were unaware of the content and original wording of the THI.
Three days after the first investigation, the inventory was answered again by randomly selected patients. All participants complained of chronic unilateral or bilateral subjective idiopathic tinnitus lasting for at least 6 months before consulting about their tinnitus. An epidemiological study in Italy based on a tinnitus questionnaire demonstrated that the prevalence of tinnitus was 8% in normal hearing subjects while this amount rose up to 30.5% in the presence of auditory dysfunctions8.
This agreed version of Persian THI translation was given to the two other translators who were expert to Persian philology (translator 3 and 4).
Finally, the results of the present investigation suggest that the THI-P was simple and clear, without losing its equivalence towards cultural issues.
All values of item-total correlation coefficient are greater than 0.3 which also indicated high internal consistency in THI-P except item 19.
An expert team composed of one of the investigators and a bilingually experienced translator reviewed the preliminary version of the THI. We calculated Pearson correlation coefficients for total item score and score for three subscales and ICCs. Results: There was no significant difference between gender, age, hearing impairment and total score and subscales of THI-P. Therefore, the valid psychometrical evaluations such as THI can be administered as a robust instrument to objectify tinnitus distress, but additional measures might be needed in order to catch the dimensions of tinnitus-related problems. Inoverall the translation quality of THI-P was evaluated as desirable from both aspects of a careful translation and adapted to the socio-cultural setting. It demonstrates adequate reliability-validity and has good internal consistency, reliability, and convergent and construct validity. Construct validity was assessed by separating the patients into three groups according to their age and to tinnitus duration. It is also useful to calculate the efficient of multiple determination (R2) by using multiple linear regression to understand the importance of an item.
Pearson product-moment correlations revealed adequate test-retest reliability for the THI-P (r = 0.96).
Also the valid questionnaires are valuable in the evaluation of results from before to after special treatment and its effect on the individual's quality of life. The Turkish version of the THI is a highly consistent and reliable measure that can be used in evaluating symptoms in tinnitus patients. Internal validity was tested by multi-item analysis to assess item convergence and discriminant validity. In this approach, one of the items is taken to be a dependent variable whereas others are taken to be independent variables.
Therefore, the symptom of tinnitus has forced clinicians to attempt to establish protocols for accuracy of tinnitus diagnosis and treatment9.
The Tinnitus Handicap Inventory (THI)25 has gained widespread acceptance as a self-report measure of tinnitus around the world.
Therefore, these translators (3 and 4) for each question determined 3 scores on the basis of 100 point criteria.
Therefore, the Persian translation of THI was not affected by hearing impairment, gender and age factors.
We asked them whether they had any difficulties in understanding the questions or had any comments regarding the content or layout of the inventory.
In this VAS, zero point means absolutely improper quality and 100 means absolutely proper and satisfactory quality.
After that, the subsequent processing was attended by audiologists from department and research center of otolaryngology of Tehran University of Medical Sciences (TUMS). According to the answers obtained from the interview and face validity test, we performed minor alterations, and our Turkish version of the THI was finalized. When an item was deleted, Cronbach's alpha for that item did not change, except for items 2, 15, and 19. Criteria for decision making in improper quality of each translation items was the average score less than 90 (determined by translators 3 and 4).
Therefore, it can be concluded that all items indicated high internal consistency (Cronbach's alpha scale, 0.886). Accordingly, in this step, Persian version of the THI was obtained, which regarding to all translators 1 to 4, had satisfactory quality.

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