Introduction

Arabic belongs to the Semitic language family. Other languages in this family include Akkadian, Amharic, Aramaic, Assyrian, Hebrew, Maltese, Phoenician, Sabaean, Tigre and Ugaritic. From this group Amharic, Arabic, Aramaic, Hebrew, Maltese and Tigre are living languages. Hebrew had been a dead language, but has been successfully revived as the language of Israel. Aramaic is still spoken in two villages in Syria, but nothing new has been written in Aramaic for awhile. Out of this group Maltese is an exception on two counts, it is written using a modified Latin alphabet and it is the one dialect of Arabic to break off and become its own language (Freeman, 1994).

Arabic critically differs from most modern European languages, not only English, in being “diglossic”. Diglossia is a term meaning two tongues formed by combining the prefix “di” (=two) and the Greek word “glossa” (=tongue or language). No discussion of Arabic is complete without at least a cursory discussion of diglossia. Charles Ferguson is credited with first using the term diglossia in an article which he wrote in 1959 called Diglossia. He identified four languages, Arabic, Greek, Haitian Creole and Swiss German as being prime examples of languages which fit into his definition of diglossia. Very simply stated, he said that diglossic speech communities have a High variety that is very prestigious and a Low variety with no official status which are in complementary distribution with each other, for instance the High variety might be used for literary discourse and the Low variety for ordinary conversation. His original definition of diglossia was that the two varieties which are in a diglossic relationship with each other are closely related, and therefore diglossia is not bilingualism. In his defining examples he points out that the High variety is always an acquired form, and that some educated native speakers might even deny that they ever use the Low variety. An important component of diglossia is that the speakers have the personal perception that the High variety is the “real” language and that the Low variety is “incorrect” usage. In Arabic people talk about the High variety as being “pure” Arabic and the dialects as being corrupt forms (Freeman, 1996).

An Arabic speaker will learn her/his own regional colloquial language (Egyptian, Moroccan, Levantine Arabic) which may have a “high prestige” dialect (Cairene, Casablancan, Beiruti Arabic) by which standards all other dialects of the region are considered backward and “countrified.” All of these dialects have different vocabularies and pronunciations, but they all share a basic syntactic structure characterized by an absence of case endings, an SVO (Subject-Verb-Object) sentence structure, loss of the dual (except in very limited cases) and a reduced number of verbal conjugations. But our hypothetical Arabic speaker will also, if s/he goes to school and wishes to be considered educated, have to learn Modern Standard Arabic, referred to as “Fus-ha”. Fus-ha form is grammatically virtually identical with the Arabic of the Quran . This “superposed” variety is considered to be the only “true” form of Arabic, and it is almost exclusively the vehicle of written communication [De Young, 1999]. It is the form used in the Arabic version of the International Outcome Inventory for Hearing Aids (IOI_HA).

The International Outcome Inventory for Hearing Aids (IOI-HA) was developed as a product of an international workshop on Self Report Outcome Measures in Audiological Rehabilitation [Cox et al., 2000]. The workshop participants recognized a need to be able to combine and compare data from different investigations and clinical service models. Thus, the inventory was developed to facilitate cooperation among researchers and program evaluators in diverse hearing healthcare settings, including across national boundaries. For this plan to be successful, it is essential to generate psychometrically equivalent translations in the languages in which hearing aid research and treatment assessments are performed [Cox et al., 2002].

The Arabic version of the IOI-HA was developed at the end of 2003. It was the twenty-second in order [http://www.ausp.memphis.edu/harl/downloads/ioifiles/Arabic.pdf]. The translation of the English IOI-HA into Arabic, was checked by at least one additional qualified individual to ensure that each item captures the nuances of the original English wording. The Hearing Aid Research Laboratory (HARL) members approved it after they were sure that it carefully followed the design principles of the original version. There are seven items in the inventory, each accessing a different self-report outcome dimension. The items were written to be unambiguous, with few cognitive requirements and at a low reading level. Negative statements and reversed meanings were avoided. An attempt was made to eschew any cultural bias. All items were designed with five possible responses. The response categories for six of the items were chosen so that their semantic distinctions (in Arabic) were roughly equal. The seventh item requires an estimate of hours of daily use. To maximize the comprehensibility of the inventory, each item has a separate response continuum, and the responses are presented so that the most favorable item appears on the right.

This work is designed to study the norms for the Arabic IOI-HA version.

Method - The IOI-HA

Items

Scoring

Normative Selection Criteria

Results

Participant Demographics

Scores

Each item was scored from 1 to 5 for the responses from right (worst) to left (best), respectively. Thus, a higher score is indicative of a better outcome. The mean score for each item is shown in Figure 1. All the mean scores fall between 2.3 and 2.7, around the middle of the scoring range.

Figure 1

Figure 1: Mean score for each IOI-HA item. Ben=benefit; RAL=residual activity limitations; Sat=satisfaction; RPR= residual participation restrictions; Ioth= impact on others; Qol= quality of life.

The distribution of scores for each item is shown in Figure 2. This figure depicts the percentage of the time that each response level was used for each item. The scattergram looks similar to a Gaussian distribution curve. “Two” and “three” scores were the most frequently used scores.

Figure 2

Figure 2: Distribution of responses for each IOI-HA Item.

Both Figures: 1 and 2, reflect that the patients had some degree of unhappiness with their hearing aids.

Effect of Demographics on IOI-HA Responses

Participants who vary in their demographics, may also yield different IOI-HA scores. This fact should be considered for the generation of the norms of the Arabic version. It was definitely noticed that both education and the type of hearing loss have clear effects on the degree of participants' satisfaction with their hearing aids. Therefore, independent T-test was used to study the effect of the different demographic characteristics on the scores of the Arabic IOI-HA. None of the seven items yielded different mean scores for gender or age groups. However, the scores of the 7 items were different with high significance when either the type of hearing loss or the level of education was addressed (Figures 3).

Figure 3

Figure 3: Mean score on each of the IOI-HA item for subjects with different types of hearing loss. SNHL= Sensorineural Hearing Loss; MHL= Mixed Hearing Loss; CHL=Conductive Hearing Loss; Use=hours of use per day; Ben=benefit; RAL=residual activity limitations; Sat=satisfaction; RPR= residual participation restrictions; Ioth= impact on others; Qol= quality of life.

Arabic IOI-HA Norms

This has been proved by ANOVA as well as Tukey Post Hoc studies that a strong association is detected between the scoring level and both the type of hearing loss (SNHL, MHL and CHL; F(1,26)=548.83. P< .001) and the level of education (Educated or Illiterate; F(1,96)=0.019.P<.001). There were a highly significant effect of both variables on the scores of the Arabic IOI-HA (Tukey Post Hoc, P<0.05). Additionally, the type of hearing loss and the education level had their highest effect on the daily use item (F(1,404)=11.956. P< .001). As a consequence, five sets for norms were developed: one for each of these categories (table 1). They included:

1. Norms for SNHL.

2. Norms for MHL.

3. Norms for CHL.

4. Norms for the Educated.

5. Norms for the Illiterate.

Figure 4

Table 1: Means (M) and Standard Deviations (SD) are given for hearing aid wearers according to the type of hearing loss or the education level. SNHL= Sensorineural Hearing Loss; MHL= Mixed Hearing Loss; CHL=Conductive Hearing Loss; EDUC= educated; ILLI=illiterate; Ben=benefit; RAL=residual activity limitations; Sat=satisfaction; RPR= residual participation restrictions; Ioth= impact on others; Qol= quality of life.

This led to the addition of 2 comments upon each copy of the inventory: one about the type of hearing loss and the other about the education level.

Discussion

Dealing with a diglossic language, like Arabic, imposed much challenge upon the provision of norms for the IOI-HA. The Arabic IOI-HA is available in the formal form of Arabic (Fus-ha form). The percentage of people aged 15 and above who can, with understanding, both read and write a short, simple statement related to their everyday life in Egypt is 56.1 % [Human Development Report-UNDP, 2001]. The ratio of literate people in this study was much lower (34%). This could be explained by the coming of most of the participants from rural areas, where hearing loss is more prevalent, due to the high rate of consanguineous marriages and consequently, the high prevalence rate of the genetic forms of hearing loss. Moreover, most of illiterate Egyptians cannot understand the exact meaning of the formal Fus-ha form of Arabic. This fact forced me to explain the different items of the IOI-HA, using the almost exact meaning, in their regional dialect orally. It was also necessary to create a chart in the form of graded colored (black to white) circles to help in the rating of each of the IOI-HA items (Appendix B).

The inclusion criteria of our patients differed markedly from the inclusion criteria used in the development of the norms of the English version [Cox et al, 2003]. The low socio-economic state as well as the strict rules of the Egyptian Health Insurance Authority, could not allow for more than one analogue BTE for each participant. All of the included participants could not afford the price of another hearing aid. This factor could have a generalized effect upon the responses of most of the participants (Fig. 1), because they mainly preferred if they had a complete-in the-canal hearing aid (CIC). Egyptians, and most of Arab people, consider it shameful to have a hearing aid behind-the-ear. This non-satisfaction could be one of the causes of the frequent scoring by grades 2 and 3 (Fig. 2). The scattergram adopted a Gaussian distribution curve figure, that implies that there was a general agreement among participants that they are unhappy with their hearing aids. This implies that the rules applied by the Health Insurance Authority in Egypt should be more flexible, even if this requires more funds.

In comparison with the English version norms of the IOI-HA [Cox et al., 2003], the average scores of the seven items were lower. The score differences ranged, in a rough approximation, from 0.5 to 1.9. However, such a comparison became nonsense after the development of different norms categorized according to the effective demographic factors in this study (Fig 3 ; table 1). It is quite evident that, the literacy as well as the better function of the cochlea and the auditory nerve, allowed more satisfaction than in any other category of the available norms. The low percent of the score 5 (Fig. 2) reflects a clear image that this satisfaction was not free from criticism. Most of the participants having conductive hearing loss, as anticipated, wished to get a CIC rather than a compression circuit.

The integration of two demographic factors, literacy and type of hearing loss, may raise the idea of creating six rather than five categories of norms (SNHL & Lit, MHL& Lit, CHL & Lit; SNHL & Illi, MHL & Illi, CHL & Illi). This was additionally approved after the results of the ANOVA and the Post Hoc statistical tests. There were a highly significant effect of both factors on the scores of the different items of the Arabic IOI-HA, especially the daily use item. This may make it much more complicated. This limitation should be overcome by the development of advanced forms of the inventory, particularly designed for diglossic languages, that can minimize the scoring differences between the literate and the illiterate, and so, only three categories of norms will be delivered. Although, all my assistants and me, did our best to minimize this variation by oral instructions and drawings (Appendix A), the difference was still wide. Moreover, illiteracy affects the cultural and the social level of the participants, and as a consequence, its effect extends to reduce the participants' ability to accept the idea of the necessity of a hearing aid for her/his condition.

Acknowledgements

Appendix A

Figure 5

Appendix B

Figure 6

Correspondence to

Mohamed Wael M. Mustafa, Department of Audiology, Hallym University, 1 Okchon-Dong, Chunchon, Kangwon-Do, Republic of Korea, 200-702. Tel: 82 10 68712312 Fax: 82 33 251 4845 E-Mail: mwaelaud@yahoo.com