Development of the Mandarin Digit-in-Noise Test and Examination of the Effect of the Number of Digits Used in the Test.

OBJECTIVES: The study aimed to develop and validate the Mandarin digit-in-noise (DIN) test using four digit (i.e., two-, three-, four-, and five-digit) sequences. Test-retest reliability and criterion validity were evaluated. How the number of digits affected the results was examined. The research might lead to more informed choice of DIN tests for populations with specific cognitive needs such as memory impairment. DESIGN: The International Collegium of Rehabilitative Audiology guideline for developing the DIN was adapted to create test materials. The test-retest reliability and psychometric function of each digit sequence were determined among young normal-hearing adults. The criterion validity of each digit sequence was determined by comparing the measured performance of older adult hearing aid users with that obtained from two other well-established sentence-in-noise tests: the Mandarin hearing-in-noise test and the Mandarin Chinese matrix test. The relation between the speech reception thresholds (SRTs) of each digit sequence of the DIN test and working memory capacity measured using the digit span test and the reading span test were explored among older adult hearing aid users. Together, the study sample consisted of 54 young normal-hearing adults and 56 older adult hearing aid users. RESULTS: The slopes associated with the two-, three-, four-, and five-digit DIN test were 16.58, 18.79, 20.42, and 21.09 %/dB, respectively, and the mean SRTs were -11.11, -10.99, -10.56, and -10.02 dB SNR, respectively. Test-retest SRTs did not differ by more than 0.74 dB across all digit sequences, suggesting good test-retest reliability. Spearman rank-order correlation coefficients between SRTs obtained using the DIN across the four digit (i.e., two-, three-, four-, and five-digit) sequences and the two sentence-in-noise tests were uniformly high ( rs = 0.9) across all participants, when data from all participants were considered. Results from the digit span test and reading span test correlated significantly with the results of the five-digit sequences ( rs = -0.37 and -0.42, respectively) but not with the results of the two-, three-, and four-digit sequences among older hearing aid users. CONCLUSIONS: While the three-digit sequence was found to be appropriate for clinical use for assessment of auditory perception, the two-digit sequence could be used for hearing screening. The five-digit sequence could be difficult for older hearing aid users, and with its SRT related to working memory capacity, its use in the evaluation of speech perception should be investigated further. The Mandarin DIN test was found to be reliable, and the findings are in line with SRTs obtained using standardized sentence tests, suggesting good criterion validity.

Development of the mandarin reading span test and confirmation of its relationship with speech perception in noise.

OBJECTIVE: This study aimed to develop a dual-task Mandarin Reading Span Test (RST) to assess verbal working memory related to speech perception in noise. DESIGN: The test material was developed taking into account psycholinguistic factors (i.e. sentence structure, number of syllables, word familiarity, and sentences plausibility), to achieve good test reliability and face validity. The relationship between the 28-sentence Mandarin RST and speech perception in noise was confirmed using three speech perception in noise measures containing varying levels of contextual and linguistic information. STUDY SAMPLE: The study comprised 42 young adults with normal hearing and 56 older adult who were hearing aid users with moderate to severe hearing loss. RESULTS: In older hearing aid users, the 28-sentence RST showed significant correlation with speech reception thresholds as measured by three Mandarin sentence in noise tests (rs or r = -.681 to -.419) but not with the 2-digit sequence Digit-in-Noise Test. CONCLUSION: The newly developed dual-task Mandarin RST, constructed with careful psycholinguistic consideration, demonstrates a significant relationship with sentence perception in noise. This suggests that the Mandarin RST could serve as a measure of verbal working memory.

Barriers to hearing aid adoption among older adults in mainland China.

OBJECTIVE: This study aimed to explore barriers to hearing aid adoption amongst older adults in mainland China. DESIGN: Semi-structured interviews were audio-recorded and analysed using qualitative thematic analysis. STUDY SAMPLE: The study included 12 older adults who had seen ENTs and had not adopted hearing aids. RESULTS: Three overarching themes and ten subthemes were generated to explain why older adults in mainland China do not adopt hearing aids: (1) Desire a cure for hearing loss, (2) Lack of a perceived need for hearing aids, and (3) Negative impressions of, and misconceptions about, hearing aids. CONCLUSION: Although barriers are similar to those reported in Western societies, the under-developed hearing healthcare infrastructure, Chinese health beliefs, Chinese culture, and low health literacy play important roles in preventing older adults to adopt hearing aids in mainland China. To identify barriers to hearing aid adoption and address them, hearing health practitioners should learn what older adults know about their hearing loss, how they perceive the effects of hearing loss, and how they feel about hearing aids.

Development and evaluation of the Cantonese matrix sentence test.

OBJECTIVE: To develop the Cantonese matrix (YUEmatrix) test according to the international standard procedure and examine possible different outcomes in another tonal language. DESIGN: A 50-word Cantonese base-matrix was established. Word-specific speech recognition functions, speech recognition thresholds (SRT), and slopes were obtained. The speech material was homogenised in intelligibility by applying level corrections up to ± 3 dB. Subsequently, the YUEmatrix test was evaluated in five aspects: training effect, test-list equivalence, test-retest reliability, establishment of reference data for normal-hearing Cantonese-speakers, and comparison with the Cantonese-Hearing-In-Noise-Test. STUDY SAMPLE: Overall, 64 normal-hearing native Cantonese-speaking listeners. RESULTS: SRT measurements with adaptive procedures resulted in a reference SRT of -9.7 ± 0.7 dB SNR for open-set and -11.1 ± 1.2 dB SNR for the closed-set response format. Fixed SNR measurements suggested a test-specific speech intelligibility function slope of 15.5 ± 0.7%/dB. Seventeen 10-sentences base test lists were confirmed to be equivalent with respect to speech intelligibility. Training effect was not observed after two measurements of 20-sentences lists. CONCLUSIONS: The YUEmatrix yields comparable results to matrix tests in other languages including Mandarin. Level adjustments to homogenise sentences appear to be less effective for tonal languages than for most other languages developed so far.

The Role of Lexical Tone Information in the Recognition of Mandarin Sentences in Listeners With Hearing Aids.

OBJECTIVES: Lexical tone information provides redundant cues for the recognition of Mandarin sentences in listeners with normal hearing in quiet conditions. The contribution of lexical tones to Mandarin sentence recognition in listeners with hearing aids (HAs) is unclear. This study aimed to remove lexical tone information and examine the effects on Mandarin sentence intelligibility in HA users. The second objective was to investigate the contribution of cognitive abilities (i.e., general cognitive ability, working memory, and attention) on Mandarin sentence perception when the presentation of lexical tone information was mismatched. DESIGN: A text-to-speech synthesis engine was used to manipulate Mandarin sentences into three test conditions: (1) a Normal Tone test condition, where no alterations were made to lexical tones within sentences; (2) a Flat Tone test condition, where lexical tones were all changed into tone 1 (i.e., the flat tone); and (3) a Random Tone test condition, where each word in test sentences was randomly assigned one of four Mandarin lexical tones. The manipulated sentence signals were presented to 32 listeners with HAs in both quiet and noisy environments at an 8 dB signal to noise ratio. RESULTS: Speech intelligibility was reduced significantly (by approximately 40 percentage points) in the presence of mismatched lexical tone information in both quiet and noise. The difficulty in correctly identifying sentences with mismatched lexical tones among adults with hearing loss was significantly greater than that of adults with normal hearing. Cognitive function was not significantly related to a decline in speech recognition scores. CONCLUSIONS: Contextual and other phonemic cues (i.e., consonants and vowels) are inadequate for HA users to perceive sentences with mismatched lexical tone contours in quiet or noise. Also, HA users with better cognitive function could not compensate for the loss of lexical tone information. These results highlight the importance of accurately representing lexical tone information for Mandarin speakers using HAs.

Development of the mandarin hearing in noise test for children.

Objectives: To develop a Mandarin version of the Hearing in Noise Test for Children (MHINT-C) and examine the maturational effects on sentence recognition.Design: Sentences suitable for evaluating children aged 6-18 years were selected from the adult MHINT to form 12 lists of 10 MHINT-C sentences (Study 1). List equivalence, inter-list reliability, response variability, and maturational effects on sentence recognition were examined using the MHINT-C (Study 2).Study sample: A total of 246 children aged 6.1-17.11 years were included. Six children participated in Study 1; the rest were included in Study 2. To compare these results with adults, 20 native Mandarin-speaking adults aged 18 or above were included in Study 2.Results: MHINT-C list equivalency, inter-list reliability, and response variability were similar to those of the adult MHINT and the Cantonese HINT for children. Sentence recognition in children reached adult-like performance around age 8 in quiet and at ages 15 and 14 in front and side noise conditions, respectively.Conclusions: The MHINT-C can reliably measure sentence recognition in quiet and noise in Mandarin-speaking children. Age-specific correction factors were established.

Transition to active learning in rural Nepal: an adaptable and scalable curriculum development model.

BACKGROUND: Traditional medical education in much of the world has historically relied on passive learning. Although active learning has been in the medical education literature for decades, its incorporation into practice has been inconsistent. We describe and analyze the implementation of a multidisciplinary continuing medical education curriculum in a rural Nepali district hospital, for which a core objective was an organizational shift towards active learning. METHODS: The intervention occurred in a district hospital in remote Nepal, staffed primarily by mid-level providers. Before the intervention, education sessions included traditional didactics. We conducted a mixed-methods needs assessment to determine the content and educational strategies for a revised curriculum. Our goal was to develop an effective, relevant, and acceptable curriculum, which could facilitate active learning. As part of the intervention, physicians acted as both learners and teachers by creating and delivering lectures. Presenters used lecture templates to prioritize clarity, relevance, and audience engagement, including discussion questions and clinical cases. Two 6-month curricular cycles were completed during the study period. Daily lecture evaluations assessed ease of understanding, relevance, clinical practice change, and participation. Periodic lecture audits recorded learner talk-time, the proportion of lecture time during which learners were talking, as a surrogate for active learning. Feedback from evaluation and audit results was provided to presenters, and pre- and post-curriculum knowledge assessment exams were conducted. RESULTS: Lecture audits showed a significant increase in learner talk-time, from 14% at baseline to 30% between months 3-6, maintained at 31% through months 6-12. Lecture evaluations demonstrated satisfaction with the curriculum. Pre- and post-curriculum knowledge assessment scores improved from 50 to 64% (difference 13.3% ± 4.5%, p = 0.006). As an outcome for the measure of organizational change, the curriculum was replicated at an additional clinical site. CONCLUSION: We demonstrate that active learning can be facilitated by implementing a new educational strategy. Lecture audits proved useful for internal program improvement. The components of the intervention which are transferable to other rural settings include the use of learners as teachers, lecture templates, and provision of immediate feedback. This curricular model could be adapted to similar settings in Nepal, and globally.

Construction and evaluation of the Mandarin Chinese matrix (CMNmatrix) sentence test for the assessment of speech recognition in noise.

OBJECTIVE: Development of the Mandarin Chinese matrix (CMNmatrix) sentence test for speech intelligibility measurements in noise according to the international standard procedure. DESIGN: A 50-word base matrix representing the distribution of phonemes and lexical tones of spoken Mandarin was established. Hundred sentences capturing all the co-articulations of two consecutive words were recorded. Word-specific speech recognition functions, speech reception thresholds (SRT: signal-to-noise ratio (SNR), that provides 50% speech intelligibility) and slopes were obtained from measurements at fixed SNRs. The speech material was homogenised in intelligibility by applying level corrections up to ± 2 dB. Subsequently, the CMNmatrix test was evaluated, the comparability of test lists was measured at two fixed SNRs. To investigate the training effect and establish the reference data, speech recognition was measured adaptively. STUDY SAMPLE: Overall, the study sample contained 80 normal-hearing native Mandarin-speaking listeners. RESULTS: Multi-centre evaluation measurements confirmed that test lists are equivalent in intelligibility, with a mean SRT of -10.1 ± 0.1 dB SNR and a slope of 13.1 ± 0.9 %/dB. The reference SRT is -9.3 ± 0.8 and -11.2 ± 1.2 dB SNR for the open- and closed-set response format, respectively. CONCLUSION: The CMNmatrix test is suitable for accurate and internationally comparable speech recognition measurements in noise.

A good practice guide for translating and adapting hearing-related questionnaires for different languages and cultures.

OBJECTIVES: To raise awareness and propose a good practice guide for translating and adapting any hearing-related questionnaire to be used for comparisons across populations divided by language or culture, and to encourage investigators to publish detailed steps. DESIGN: From a synthesis of existing guidelines, we propose important considerations for getting started, followed by six early steps: (1) Preparation, (2, 3) Translation steps, (4) Committee Review, (5) Field testing and (6) Reviewing and finalising the translation. STUDY SAMPLE: Not applicable. RESULTS: Across these six steps, 22 different items are specified for creating a questionnaire that promotes equivalence to the original by accounting for any cultural differences. Published examples illustrate how these steps have been implemented and reported, with shared experiences from the authors, members of the International Collegium of Rehabilitative Audiology and TINnitus research NETwork. CONCLUSIONS: A checklist of the preferred reporting items is included to help researchers and clinicians make informed choices about conducting or omitting any items. We also recommend using the checklist to document these decisions in any resulting report or publication. Following this step-by-step guide would promote quality assurance in multinational trials and outcome evaluations but, to confirm functional equivalence, large-scale evaluation of psychometric properties should follow.

Speech perception in Mandarin-speaking children with cochlear implants: A systematic review.

OBJECTIVE: This paper reviewed the literature on the trajectories and the factors significantly affecting post-implantation speech perception development in Mandarin-speaking children with cochlear implants (CIs). DESIGN: A systematic literature search of textbooks and peer-reviewed published journal articles in online bibliographic databases was conducted. STUDY SAMPLE: PubMed, Scopus and Wiley online library were searched for eligible studies based on predefined inclusion and exclusion criteria. RESULTS: A total of 14 journal articles were selected for this review. A number of consistent results were found. That is, children with CIs, as a group, exhibited steep improvement in early speech perception, from exhibiting few prelingual auditory behaviours before implantation to identifying sentences in noise after one year of CI use. After one to three years of CI use, children are expected to identify tones above chance and recognition of words in noise. In addition, early age at implantation, longer duration of CI use and higher maternal education level contributed to greater improvements in speech perception. CONCLUSIONS: Findings from this review will contribute to the establishment of appropriate short-term developmental goals for Mandarin-speaking children with CIs in mainland China and clinicians could use them to determine whether children have made appropriate progress with CIs.

International Collegium of Rehabilitative Audiology (ICRA) recommendations for the construction of multilingual speech tests. ICRA Working Group on Multilingual Speech Tests.

OBJECTIVE: To provide guidelines for the development of two types of closed-set speech-perception tests that can be applied and interpreted in the same way across languages. The guidelines cover the digit triplet and the matrix sentence tests that are most commonly used to test speech recognition in noise. They were developed by a working group on Multilingual Speech Tests of the International Collegium of Rehabilitative Audiology (ICRA). DESIGN: The recommendations are based on reviews of existing evaluations of the digit triplet and matrix tests as well as on the research experience of members of the ICRA Working Group. They represent the results of a consensus process. RESULTS: The resulting recommendations deal with: Test design and word selection; Talker characteristics; Audio recording and stimulus preparation; Masking noise; Test administration; and Test validation. CONCLUSIONS: By following these guidelines for the development of any new test of this kind, clinicians and researchers working in any language will be able to perform tests whose results can be compared and combined in cross-language studies.

An Exploration of the Memory Performance in Older Adult Hearing Aid Users on the Integrated Digit-in-Noise Test.

This study aimed to preliminarily investigate the associations between performance on the integrated Digit-in-Noise Test (iDIN) and performance on measures of general cognition and working memory (WM). The study recruited 81 older adult hearing aid users between 60 and 95 years of age with bilateral moderate to severe hearing loss. The Chinese version of the Montreal Cognitive Assessment Basic (MoCA-BC) was used to screen older adults for mild cognitive impairment. Speech reception thresholds (SRTs) were measured using 2- to 5-digit sequences of the Mandarin iDIN. The differences in SRT between five-digit and two-digit sequences (SRT5-2), and between five-digit and three-digit sequences (SRT5-3), were used as indicators of memory performance. The results were compared to those from the Digit Span Test and Corsi Blocks Tapping Test, which evaluate WM and attention capacity. SRT5-2 and SRT5-3 demonstrated significant correlations with the three cognitive function tests (rs ranging from -.705 to -.528). Furthermore, SRT5-2 and SRT5-3 were significantly higher in participants who failed the MoCA-BC screening compared to those who passed. The findings show associations between performance on the iDIN and performance on memory tests. However, further validation and exploration are needed to fully establish its effectiveness and efficacy.

Delayed presentation is associated with serious bacterial infections among febrile infants: A prospective cohort study.

Introduction: Febrile young infants are at risk of serious bacterial infections (SBIs), which are potentially life-threatening. This study aims to investigate the association between delayed presentation and the risk of SBIs among febrile infants. Method: We performed a prospective cohort study on febrile infants ≤90 days old presenting to a Singapore paediatric emergency department (ED) between November 2017 and July 2022. We defined delayed presentation as presentation to the ED >24 hours from fever onset. We compared the proportion of SBIs in infants who had delayed presentation compared to those without, and their clinical outcomes. We also performed a multivariable logistic regression to study if delayed presentation was independently associated with the presence of SBIs. Results: Among 1911 febrile infants analysed, 198 infants (10%) had delayed presentation. Febrile infants with delayed presentation were more likely to have SBIs (28.8% versus [vs] 16.3%, P<0.001). A higher proportion of infants with delayed presentation required intravenous antibiotics (64.1% vs 51.9%, P=0.001). After adjusting for age, sex and severity index score, delayed presentation was independently associated with the presence of SBI (adjusted odds ratio [AOR] 1.78, 95% confidence interval 1.26-2.52, P<0.001). Conclusion: Febrile infants with delayed presentation are at higher risk of SBI. Frontline clinicians should take this into account when assessing febrile infants.

Adaptation of scoring methods for testing cochlear implant users using the Cantonese Hearing In Noise Test (CHINT).

OBJECTIVES: It is often difficult to use an adaptive approach to evaluate speech reception in noise in cochlear implant (CI) users, because of variations in performance. Thus, two studies were conducted to develop an alternative method for scoring the Cantonese Hearing In Noise Test (CHINT) and to use this method for evaluating speech reception in CI users. DESIGN: In Study 1, 20 normal-hearing adults were tested using four scoring methods, including three modified and the standard HINT scoring method. The speech was presented in the front, and noise originated from the front, the right, or the left loudspeakers, as a standard HINT protocol. Threshold signal-to-noise ratio (S/N) and word intelligibility percent score (word score) were measured in each CHINT noise condition using each rule. In Study 2, depending on the word score of the individual CI user in the quiet CHINT condition, different adaptive rules were selected to score the responses from 12 CI users in the three noise conditions. The percentage of CI users who could successfully be tested using these scoring methods was evaluated. RESULTS: In Study 1, threshold S/Ns obtained using different rules were significantly different and consistent with expectations. The slopes of the performance-intensity function relating mean word scores and threshold S/Ns were linear and agreed well with previous findings. These results showed that the modified rules could be used to adaptively measure CHINT thresholds in noise. In Study 2, these modified rules were successful in measuring CHINT thresholds in 10 of the 12 participants, whose word scores in quiet exceeded 40%. CONCLUSIONS: These modified rules could be used in CI users whose speech reception ability could not have been measured otherwise.

Assessing the perceptual contributions of vowels and consonants to Mandarin sentence intelligibility.

This study investigated the perceptual contributions of vowels and consonants to Mandarin sentence intelligibility. Mandarin sentences were edited using a noise-replacement paradigm to preserve various amounts of segmental information and presented to normal-hearing listeners to recognize. The vowel-only Mandarin sentences yielded a remarkable 3:1 intelligibility advantage over the consonant-only sentences. This advantage is larger than that obtained with English sentences, suggesting that vowels may have a greater contribution to sentence intelligibility in Mandarin than in English. Although providing information redundant to contributions from vowel centers, a little vowel-consonant boundary transition would significantly improve the intelligibility of the consonant-only Mandarin sentences.

Hearing-aid assembly management among adults from culturally and linguistically diverse backgrounds: toward the feasibility of self-fitting hearing aids.

OBJECTIVE: The purpose of the study was twofold: (1) to assess the ability of hearing-impaired adults in the developing world to independently and accurately assemble a pair of hearing aids by following instructions that were written and illustrated according to best-practice health literacy principles; and (2) to determine which factors influence independent and accurate task completion. DESIGN: Correlational study. STUDY SAMPLE: Forty South African and 40 Chinese adults with a hearing loss and their partners. The participant group included 42 females and 38 males ranging in age from 32 to 92 years. RESULTS: Ninety-five percent of South African and 60% of Chinese participants completed the assembly task, either on their own or with assistance from their partners. Better health literacy, younger age, and a more prestigious occupation were significantly associated with independent task completion for the South African and Chinese participants. Task accuracy was significantly linked to higher levels of cognitive function among South African participants, while a paucity of valid data prevented an analysis of accuracy from being conducted with the Chinese data. CONCLUSION: Individuals of diverse backgrounds can manage the self-fitting hearing-aid assembly task as long as health literacy levels and cultural differences are considered.

Discrimination of consonants in quiet and in noise in Mandarin-speaking children with normal hearing.

OBJECTIVE: Given the critical role of consonants in speech perception and the lack of knowledge on consonant perception in noise in Mandarin-speaking children, the current study aimed to investigate Mandarin consonant discrimination in normal-hearing children, in relation to the effects of age and signal-to-noise ratios (S/N). DESIGN: A discrimination task consisting of 33 minimal pairs in monosyllabic words was designed to explore the development of consonant discrimination in five test conditions: 0, -5, -10, -15 dB S/Ns, and quiet. STUDY SAMPLE: Forty Mandarin-speaking, normal-hearing children aged from 4;0 to 8;9 in one-year-age increment were recruited and their performance was compared to 10 adult listeners. RESULTS: A significant main effect of age, test conditions, and an interaction effect between these variables was noted. Consonant discrimination in quiet and in noise improved as children became older. Consonants that were difficult to discriminate in quiet and in noise were mainly velar contrasts. Noise seemed to have less effect on the discrimination of affricates and fricatives, and plosives appeared to be to be more difficult to discriminate in noise than in quiet. Place contrasts between alveolar and palato-alveolar consonants were difficult in quiet. CONCLUSIONS: The findings were the first to reveal typical perceptual development of Mandarin consonant discrimination in children and can serve as a reference for comparison with children with disordered perceptual development, such as those with hearing loss.

Characterization of speech understanding in various types of noise.

This study examined (1) the effects of noise on speech understanding and (2) whether performance in real-life noises could be predicted based on performance in steady-state speech-spectrum-shaped noise. The noise conditions included a steady-state speech-spectrum-shaped noise and six types of real-life noise. Thirty normal-hearing adults were tested using sentence materials from the Cantonese Hearing In Noise Test (CHINT). To achieve the first aim, the performance-intensity function slopes in these noise conditions were estimated and compared. Variations in performance-intensity function slopes were attributed to differences in the amount of amplitude fluctuations and the presence of competing background speech. How well the data obtained in real-life noises fit the performance-intensity functions obtained in steady-state speech-spectrum-shaped noises was examined for the second aim of the study. Four out of six types of noise yielded performance-intensity function slopes similar to that in steady-state speech-spectrum-shaped noise. After accounting for individual differences in sentence reception threshold (SRT) and the offset between the signal-to-noise ratio for 50% intelligibility across different types of noise, performance in steady-state speech-spectrum-shaped noise was found to predict well the performance in most of the real-life noise conditions.

The effects of binaural spectral resolution mismatch on Mandarin speech perception in simulated electric hearing.

This study assessed the effects of binaural spectral resolution mismatch on the intelligibility of Mandarin speech in noise using bilateral cochlear implant simulations. Noise-vocoded Mandarin speech, corrupted by speech-shaped noise at 0 and 5 dB signal-to-noise ratios, were presented unilaterally or bilaterally to normal-hearing listeners with mismatched spectral resolution between ears. Significant binaural benefits for Mandarin speech recognition were observed only with matched spectral resolution between ears. In addition, the performance of tone identification was more robust to noise than that of sentence recognition, suggesting factors other than tone identification might account more for the degraded sentence recognition in noise.