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Translation and validation of tinnitus handicap inventory into Gujarati language

Tinnitus is an aberrant perception of sound without any external stimulus. Tinnitus impinges on the quality of life of affected individuals to varying degrees occurring as a minor irritation to some and in extreme cases result in the intentional or ambivalent self destructive act of suicide. There is no direct method to quantify tinnitus in an individual. However, there are various validated questionnaires available which help in quantifying the effect of tinnitus on the quality of life. Of these, tinnitus handicap inventory (THI) is widely used worldwide to quantify the handicap due to tinnitus. THI was developed in English language in 1996 by Newmann et al as a 25 item questionnaire with three subscales (functional, emotional and catastrophic). Since THI is a self administered questionnaire, it is imperative that patient understands the language. Hence, THI has been translated and validated in various foreign languages. As far as Indian languages are concerned, THI has been developed in Tamil, Kannada and Malayalam. Hence, a need was felt to develop THI into Gujarati language so that is can easily be administered to the Gujarati speaking population.


INTRODUCTION
Tinnitus is an aberrant perception of sound without any external stimulus. Tinnitus impinges on the quality of life of affected individuals to varying degrees occurring as a minor irritation to some and in extreme cases result in the intentional or ambivalent self destructive act of suicide. 1 There is no direct method to quantify tinnitus in an individual. However, there are various validated questionnaires available which help in quantifying the effect of tinnitus on the quality of life. Of these, tinnitus handicap inventory (THI) is widely used worldwide to quantify the handicap due to tinnitus. THI was developed in English language in 1996 by Newmann et al as a 25 item questionnaire with three subscales (functional, emotional and catastrophic). 2 Since THI is a self administered questionnaire, it is imperative that patient understands the language. Hence, THI has been translated and validated in various foreign languages. As far as Indian languages are concerned, THI has been developed in Tamil, Kannada and Malayalam. [3][4][5] Hence, a need was felt to develop THI into Gujarati language so that is can easily be administered to the Gujarati speaking population.

Inclusion criteria
All adult patients (aged 18 to 60 years) who complained of tinnitus of more than three months duration were included in the study.

Exclusion criteria
Exclusion criteria were patients with any pre-existing ear pathology; patients who did not give consent for the study.
68 patients fulfilled the inclusion criteria. A thorough clinical ENT examination was done for all patients. A written and informed consent was taken from all the participants. All patients could read and speak Gujarati. All patients were asked to fill the THI-Guj and a health professional was made available for any help required.

Translation of THI into Gujarati
THI in English was given to five persons who were proficient in Gujarati and English languages. Translationback translation method was used. Any discrepancies in the five questionnaires developed were sorted by general consensus. The final THI in Gujarati (THI-Guj) was given to 20 native Gujarati speaking people to check for content validity (Appendix I). These subjects were asked to rate each item of the questionnaire on a Likert"s scale from 1 to 5, with 1 being "highly acceptable" and 5 "not acceptable". All items received a rating of either 1 or 2 and hence all were retained.
All the completed inventories were analyzed by the first author and scores were calculated. SPSS statistics 21.0 (SPSS Inc. Chicago) was used for statistical analysis.
To check the reliability of THI-Guj, Cronbach"s Alpha test was applied and the overall score was.980 (Table 2). A reliability coefficient of.70 or higher is considered "acceptable" in most social science research situations. Hence the developed inventory was found to be acceptable and reliable.    Further in-depth analysis of the questionnaire for reliability and internal consistency was done and results are shown in Table 3.
The item total correlation is a correlation between the question score (e.g., 0 or 1 for multiple choice) and the overall assessment score. It is expected that if a participant gets a question correct they should, in general, have higher overall assessment scores than participants who get a question wrong. A small item-correlation provides empirical evidence that the item is not measuring the same construct measured by the other items included. A correlation value less than 0.2 or 0.3 indicates that the corresponding item does not correlate very well with the scale overall and, thus, it may be dropped. Table 3 presents the value that Cronbach's alpha would be if that particular item was deleted from the scale. We can see that removal of any item, except items 9, 11 and 15, would result in a lower Cronbach's alpha. Therefore, we would not want to remove these questions. Removal of questions 9, 11 and 15 would lead to a small improvement in Cronbach's alpha. However, the Corrected item-total correction value of these items was above the acceptable limit (>0.3), hence these items were retained in the questionnaire.
Cronbach"s alpha test was further applied on the three subscales (functional, emotional and catastrophic) of THI-Guj and results were shown in Table 4. Overall Cronbach"s alpha score for three subscales was. 910 indicating that THI-Guj was reliable and consistent.

DISCUSSION
Tinnitus is a significant condition that may be a burden for people affected. Therefore, it is important to validate tinnitus assessment questionnaires among different agegroups and in different languages. While tinnitus occurs in individuals of all age groups, it most commonly occurs among adults. The problem of tinnitus in India is also as alarming and as severe as in the Western countries; but studies regarding the psychological profiles of individuals with tinnitus are very limited and some studies in India have attempted to reveal the relation between the perceived tinnitus severity and the degree of emotional distress of the individuals. 6,7 Various tools have been designed to evaluate the effect of tinnitus; some of these are tinnitus handicap questionnaire, tinnitus severity questionnaire, tinnitus handicap inventory and tinnitus functional index. THI is a very useful tool to measure the degree of handicap due to tinnitus. It is easy to administer and interpret, broad in scope, and psychometrically robust. In the present study, THI-Guj could classify the patients according to severity of tinnitus ( Table 1).
The first THI was developed by the British Association of Otolaryngologist, Head and Neck Surgeons which consists of 50 questions. Newman et al developed the 25item inventory which was grouped appropriately into three subscales (functional, emotional, and catastrophic). Functional subscale had 11 questions, emotional had 9, while catastrophic had 5 questions. Since then, THI has been adapted in various languages -Hebrew, Mandarin, Hungarian, French and Russian, to mention just the most recent. [8][9][10][11][12] All previous authors of THI adaptations have confirmed the validity and reliability of their versions. The English version of THI has got a Cronbach"s alpha score of 0.93 with an Item-Total Correlation ranging between 0.22-0.77. 13 Similarly, the Cronbach"s alpha score for French and Hungarian version was 0.92 and 0.95 respectively. The present developed inventory also had acceptable reliability scores (Table 2 and 3). The results of the present investigation demonstrated that the THI-Guj has an excellent consistency reliability for the total scale (α=0.98) and is adequate for the functional (α=0.848), emotional (α=0.853) and catastrophic (α=0.896) subscales (Table 4).

Construct validity
In order to establish construct validity, the total score on each subscale (i.e. functional, emotional and catastrophic) was correlated with all other subscales and also with the total THI-Guj score. Correlation was found to be significant (p=0.000) across all three subscales and with the total THI-Guj score. This revealed that the subscales consistently measured the attributes they intended to measure.

CONCLUSION
Statistical results obtained for the Gujarati version of THI (THI-Guj) show a good reliability/ internal consistency as indicated by the Cronbach"s alpha and corrected Itemtotal correlation score. Hence, this inventory can be used in assessment and monitoring of tinnitus sufferers, who are Gujarati speakers, by audiologist as well as otologists working in various clinical settings across the state. There is a need to validate and translate THI into various local languages so that it can be effectively implemented.