Purpose: The study aims to evaluate the internal consistency and test-retest reliability of the Arabic Speech, Spatial, and Qualities of Hearing Scale (SSQ12-Arab) among Arabic-speaking individuals with hearing impairment. Additionally, it aims to compare the responses between individuals with hearing loss and those with normal hearing, highlighting the importance of patient-reported outcomes in evaluating hearing aid benefits. Methods: This cross-sectional study was conducted at two hearing clinics in the city of Nablus, Palestine, from April to June 2024. The study included 60 participants, divided into two groups: 30 individuals with hearing impairment and 30 individuals in a control group with normal hearing. The study measured reliability, internal consistency, and significant differences in total scores among the two groups. Results: The Arabic SSQ12 demonstrated overall internal consistency and test-retest reliability. A significant difference was found between the SSQ12 scores of the hearing-impaired group and the control group, indicating distinct communication abilities. Conclusion: The Arabic SSQ12 is a reliable and valid tool for assessing the communication capabilities of patients with hearing loss in audiology clinics. Future research should investigate differences in SSQ12 total scores among various types of hearing loss, such as bilateral versus unilateral or monaural versus binaural hearing aid fittings. Keywords: hearing impairment, normal hearing, patient-reported outcomes (PROs), SSQ12-Arab, test-retest reliability INTRODUCTION Hearing loss affects individuals’ ability to engage in various settings and has a profoundly negative impact on their quality of life.1 The International Classification of Impairment (ICF) differentiates between hearing disability, limitation, and participation restriction. Hearing disability is a measurable impairment of hearing by objective instruments in the clinic. In terms of limitations, this may include an inability of the person to hear in noisy environments. In contrast, restrictions may relate to how this disability prevents individuals from fulfilling their role in society, restricting their participation in everyday life.2Figure 1: The mean score of question 9 for NH, CHL, SNHL, and Mixed HLTable 1: Descriptive Statistics of Values by a Question from the SSQ12 for Groups with Normal Hearing and with Hearing LossTable 2: SSQ12 Total ScoresTable 3: Analysis of Variance of Total Scores (12 Items) for Groups With Normal Hearing and with Hearing LossTable 4: Post Hoc Test: Multiple Comparisons of SSQ12 Total ScoresTable 5: Cronbach’s Alpha Coefficient of SSQ12 for Each GroupTable 6: Internal Consistency Results of the Arabic Speech, Spatial, and Qualities of Hearing Scale (SSQ12) Questionnaire with Normal Hearing GroupTable 7: Internal Consistency Results of the Arabic Speech, Spatial, and Qualities of Hearing Scale (SSQ12) Questionnaire with the Hearing-Impaired GroupTable 8: Internal Consistency Results of the Arabic Speech, Spatial, and Qualities of Hearing Scale (SSQ12) Questionnaire with the Whole SampleIn real life, hearing disability is measured by objective methods such as pure tone audiometry and speech audiometry tests, which are the primary focus among health professionals in comparison with the domains of limitation and participation restriction.3,4 Overemphasis by audiologists on audiological objective measures to ensure the hearing aid benefit is not considered best practice.5 Instead, other measures should be utilized to reflect the individuals’ satisfaction with their hearing aids, which will ultimately reflect their quality of life.6 Patient-reported outcomes (PROs) may offer a holistic perspective, allowing healthcare professionals to tailor interventions and treatments to meet individual needs.7 By incorporating the patient’s perspective, PROs not only help in assessing the efficacy of interventions but also aid in setting realistic goals, enhancing patient satisfaction, and promoting shared decision-making. Furthermore, PROs empower patients by acknowledging their unique challenges, advocating for comprehensive care, and improving their overall well-being.8 Different standardized self-reported questionnaires were published for clinical use, such as the Communication Profile for the Hearing Impaired, the Hearing Handicap Inventory for the Elderly, International Outcome Inventory for Hearing Aids, and the Speech, Spatial and Qualities of Hearing Scale (SSQ).9–12 The original Speech, Spatial and Qualities of Hearing Scale (SSQ49) contained 49 items that assessed a range of listening situations in daily life. Although the SSQ49 provides a thorough assessment of listeners’ experiences, its effectiveness in the clinic can be limited due to its length and administration difficulty. Therefore, SSQ49 was adjusted to consist of five items used as a screening tool with good sensitivity and specificity.4 Fifteen items of the SSQ were also established as a supplement to binaural hearing function laboratory tests in epidemiological settings.13 Unlike previous versions, SSQ12 was designed in 2013 to provide clinicians and researchers with a scaled-down version of the original scale. There has been evidence in large clinical research samples that the SSQ12 offered similar results to the SSQ49.14 The SSQ is the most commonly used self-report questionnaire which assesses individuals’ abilities in three major domains: 1) Speech (speech understanding in different settings like noise and quiet), 2) Spatial (effects of distance and movement on hearing) and 3) Qualities (Identification of the sound and their naturalness as well as listening efforts).15 The SSQ questionnaire is a strong and effective tool for different purposes. For instance, in adult patients who undergo bilateral cochlear implants (CIs), subjective and objective outcomes have been compared—a comparison of SSQ results between two groups with minimal hearing loss and an assessment of the hearing abilities of patients with unilateral hearing loss using the SSQ questionnaire.16–19 Results of these studies indicated that using the SSQ has demonstrated its value in capturing subjective listening outcomes across different hearing conditions. For instance, in adults with CIs, Hua et al. found that combining a CI with a frequency-transposing hearing aid in the contralateral ear led to higher SSQ ratings, with participants reporting improved speech perception in noise, enhanced spatial hearing, and better sound quality compared to using the implant alone.16 Similarly, Laske et al. observed that bilateral CI users generally achieved higher SSQ scores than unilateral users, particularly in spatial hearing tasks such as localization and directionality, as well as in complex listening environments, though not all differences reached statistical significance.17 Beyond cochlear implantation, Banh et al. compared younger and older adults with minimal audiometric hearing loss and showed that older participants consistently reported lower SSQ ratings, especially in demanding conditions such as speech in noise, highlighting the influence of age on perceived hearing difficulties even when thresholds are nearly normal.18 Finally, research on unilateral sensorineural hearing loss indicated that affected individuals experienced significant challenges across all SSQ domains, particularly in speech perception, localization, and complex auditory scenes, compared to those with normal binaural hearing.20 SSQ was translated into several languages, such as Portuguese, Turkish, and Spanish and was used in clinical settings.15,21,22 In 2021, the SSQ12 was translated into Arabic and administered to Saudi patients with sensorineural hearing loss (SNHL).23 This study concluded that the SSQ12 Arabic Version can assess the hearing ability of individuals with SNHL in various daily settings with excellent internal consistency ( = 0.9) and good test-retest reliability (intraclass correlation coefficient ICC = 0.8).24 THE PURPOSE OF THE STUDY With the SSQ12, Arabic speakers with hearing impairment can express the challenges they face due to their hearing impairments. Arabic-speaking audiologists can also use SSQ12 with other audiological assessments to examine how hearing loss impacts their clients’ hearing abilities and evaluate the hearing status in different settings. Based on Alkhodair et al.’s findings, this study aimed to test the internal consistency and test-retest reliability of SSQ12 in assessing the hearing disabilities in daily life among aided adults with all types of hearing loss (i.e., conductive, sensorineural, and mixed hearing loss) in Palestine.23 It also compared the responses between the two groups (hearing impaired and normal hearing). METHODS This cross-sectional study was conducted between April and June 2024 and recruited a convenience sample from two hearing centers in Nablus, Palestine, due to Israeli-imposed road restrictions. Center approvals were obtained, and all participants provided written informed consent before questionnaires and data collection. PARTICIPANTS The study included 60 adults, divided into two groups: 30 with hearing loss and 30 with normal hearing. The hearing loss group was recruited from two hearing centers in Nablus and included 10 participants with conductive hearing loss, 10 with sensorineural hearing loss, and 10 with mixed hearing loss. The control group consisted of individuals with normal hearing and no current or previous history of hearing disorders. Each group included an equal number of males and females (15 males and 15 females). The mean age of the hearing loss group was 41.1 ± 19.0 years, whereas the mean age of the normal hearing group was 24.8 ± 6.27 years. Most participants were between 18 and 28 years of age. The hearing-impaired participants were eligible for inclusion if they were 18 years or older and had been diagnosed with hearing loss based on their pure tone average (PTA; i.e., 500, 1,000, 2,000, and 4,000 Hz ≥ 20 dB).22,23 Their native language was Arabic, and neither cognitive nor intellectual deficits were reported by the participants nor appeared to be present to the investigators. No distinction was made regarding the number of hearing aids used (unilateral or bilateral). The study excluded patients who were illiterate or gave incomplete answers to the questionnaire. Participants with normal hearing were eligible for inclusion if they were 18 years or older, with (PTA ≤ 20 dB).22,23 The participants did not report any current or previous hearing-related problems, did not exhibit cognitive or intellectual issues, and spoke Arabic as their native language. The cognitive abilities of the participants were screened using the Arabic Montreal Cognitive Assessment (MoCA).25,26 PROCEDURES After obtaining approval from both the centers and participants, the Arabic Montreal Cognitive Assessment (MoCA) was administered as a cognitive screening tool.25,26 The screening was performed by a certified MoCA occupational therapist (OT). The OT was responsible for administering, scoring, and interpreting the results. Participants with MoCA total scores of 26 to 30 are considered to have normal cognitive functioning; therefore, they were included in the study. A score below 26 indicates some degree of cognitive impairment, so those individuals were excluded from the study.26,27 Following the cognitive screening, an online questionnaire containing general questions (e.g., age, gender, phone number) and SSQ12 questions were sent to the participants’ mobile phones before conducting hearing tests. For each situation, participants rated their communication performance on a scale of 0 to 10. A brief explanation was provided: participants were instructed to rate 10 if they could perform the described scenario perfectly, and 0 if they were unable to do it. An additional option, “not applicable,” was available if the situation did not reflect the participant’s daily experiences. For participants with visual impairments or those who were illiterate, the researcher read the SSQ12 scale questions aloud to assist them. After completing the questionnaire, pure tone audiometry was administered at octave frequencies (500 to 8 kHz). A tympanogram of 226 Hz probe tone assesses middle ear status. The group with normal-hearing (NH) consisted of participants with hearing thresholds of 20 dB or less based on the pure-tone average. In contrast, the group with hearing-impaired (HI) consisted of participants with a PTA > 20 dB in one or both ears without wearing hearing aids.22,23 The Arabic SSQ12 was re-administered to 30 participants who were chosen randomly (15 with hearing impairment and 15 with normal hearing) two weeks after the initial assessment to measure the test-retest reliability. In this analysis, only fully completed questionnaires were considered. DATA ANALYSIS Statistical Package for the Social Sciences (SPSS) version 23.0 was used for data analysis. Descriptive statistics were used to describe the mean, median, and standard deviation data, and to check the normality of the SSQ12 total scores. The Levene test was used to test the homogeneity of variances for the SSQ12 total scores. An analysis of variance (ANOVA) was performed to determine if there was a significant difference in total scores across hearing status categories (i.e., normal hearing, conductive hearing loss, sensorineural hearing loss, and mixed hearing loss). The intraclass correlation coefficient (ICC) was used to assess the test-retest reliability. The internal consistency was measured using Cronbach’s alpha coefficient of the 12 items for each group and the whole sample. Internal consistency ranges from 0 to 1. Generally, an value of (0.7 ≤ 0.0001), where subjects with hearing loss scored significantly lower than participants without hearing loss. As shown in Table 1, the means of total scores on the 12-item SSQ are described by groups (see Appendix). The mean performance of each group by question showed a difference between the normal hearing and hearing loss groups for most items. However, there was no significant difference between the groups’ means in item number 9. The item states, “When you hear more than one sound at a time, do you have the impression that it seems like a single jumbled sound?” (See Fig. 1.) Levene test for assessing the homogeneity of variances was applied to test the homogeneity of SSQ12 total scores. The results showed no significant variance differences (p = 0.294) since the significance 0.294 > 0.05. According to Table 2, participants with normal hearing reported the highest total scores SSQ12 (M = 85.6; SD = 14.30), followed by those with mixed hearing loss (M = 65.0; SD = 16.67) and conductive hearing loss (M = 64.7; SD = 20.98) with the lowest scores being reported by those with sensorineural hearing loss (M = 51.60; SD = 20.46). A one-way between-subjects ANOVA was conducted to compare the effect of hearing status on the SSQ12 scores for adults with normal hearing, conductive, sensorineural, and mixed hearing loss. The results indicated a significant impact of the degree of hearing on the SSQ12 total scores for the participants at the p 0.0001] (see Table 3). To further examine the differences, the post hoc test was conducted (see Table 4). In the post hoc table, each row presents one group contrasted against the others. It shows which pairs of means differ significantly, with a p value < 0.05. The mean difference between individuals with normal hearing and those with conductive hearing loss is statistically significant (p value = 0.008). Similarly, the differences between normal hearing and sensorineural hearing loss (p = 0.005) and between normal hearing and mixed hearing loss (p = 0.009) are also significant. No other mean differences are statistically significant. SSQ’s internal consistency was determined by Cronbach’s alpha coefficient for each group of 12 items separately and as a whole sample, reflecting good internal consistency ( = 0.881). Table 5 shows a significant correlation between items for both groups. In addition, Cronbach’s alpha value for the normal hearing group ranged from (0.669–0.743) and (0.739–0.781) for the hearing-impaired group if any of the 12 questions were deleted. Tables (6, 7, and 8) show that the best Cronbach’s alpha was obtained when question twelve was deleted for either of the two groups. Test-retest in the sub-sample of normal-hearing and hearing-impaired individuals who completed the questionnaire twice (n = 15) for each group showed a good consistency for SSQ12 overall scores between the first (M = 84.3, SD = 15.8) and second administration (M = 85.9, SD = 15.7) for normal hearing group, and the hearing-impaired group as follow respectively (M = 52.4, SD = 18.4) and (M = 52.2, SD = 18.4). Moreover, the intraclass correlation coefficient was 0.999 (95% CI), reflecting excellent reliability (See Tables 6, 7, and 8). DISCUSSION One of the most widely used self-reported measures for assessing “hearing disability” is the SSQ.18,29–31 This questionnaire assesses the auditory difficulties experienced by individuals in their daily life settings. This approach describes auditory functionality as a perception of disability based on interactions between those who perceive disability and their familiar auditory environment.7 Generally, traditional clinical hearing test methods do not reflect patients’ hearing performance in real-life situations; therefore, PROs can effectively capture everyday experiences.32 A 12-item version of the SSQ was developed and translated into different languages based on multi-center studies and factor analysis.14 The purpose of the current study was to test the internal consistency and test-retest reliability of the Arabic Version of SQQ12 in evaluating the auditory abilities in daily life among adults with all types of hearing loss (i.e., conductive, sensorineural, and mixed hearing loss) in Palestine. It also compared the responses between the hearing-impaired and normal-hearing groups. The results indicated that Arabic SSQ12 showed good internal consistency for the whole sample represented by Cronbach’s alpha which was reported to be ( = 0.881), displaying lower results than a previous study conducted on Saudi patients with sensorineural hearing loss ( = 0.94), and nearly similar results to prior studies in other languages.23,33,34 Cronbach’s alpha value remained suitable for the whole group, ranging from (.835–.861), even if a question was and this is a lower value compared to Alkhodair and findings, which they reported a Cronbach’s alpha value for the whole group of range from if a question was was also found on the SSQ12 with a test-retest correlation = which is higher than the of a previous study on Saudi individuals = and other similar studies of other languages that reported test-retest reliability ranging from to There was a significant difference in on the Arabic Version of the SSQ12 between normal and hearing-impaired both for individual questions and total as shown in Table results indicate that the questionnaire can between hearing-impaired and normal hearing and this with previous The results also that the SSQ12 a of experienced by hearing-impaired individuals in everyday listening The difference in scores between normal and impaired hearing groups was not for question the mean score for normal hearing is whereas for the hearing-impaired group is (see Table and Appendix). question 9 is not a significant of hearing loss (i.e., it is not for the or of hearing loss). 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