The validity and reliability of the Thai version of the Cochlear Implant Quality of Life questionnaire

Abstract

Objective:

Improving quality of life is one of the most important outcomes following cochlear implantation, and this can be effectively evaluated using disease-specific questionnaires. However, no such quality of life questionnaire currently exists in the Thai language for cochlear implant recipients. This study aimed to translate and validate the Cochlear Implant Quality of Life questionnaire into Thai.

Methods:

The original Cochlear Implant Quality of Life questionnaire consists of 35 items across six subdomains. The translation followed Hall’s guideline for cross-cultural adaptation. Content validity was reviewed by three experts and 10 healthy participants.

Results:

After the translation process, the Thai version of the Cochlear Implant Quality of Life demonstrated strong content validity, achieving an Index of Item-Objective Congruence score of 1.0 across all items as assessed by three experts. A review by 10 healthy participants using a five-point Likert scale yielded a mean score of 4.71 (SD = 0.20; range: 4.35–5.00), confirming item clarity and relevance. In testing with 19 cochlear implant users, the Thai version of the Cochlear Implant Quality of Life demonstrated high internal consistency (Cronbach’s alpha > 0.6) and good test–retest reliability (r > 0.75) across most subdomains. Moderate reliability was observed in three subdomains: communication (r = 0.512), environment (r = 0.745), and listening effort (r = 0.426).

Conclusion:

The Thai version of the Cochlear Implant Quality of Life is a valid and reliable instrument for assessing quality of life in adult cochlear implant users. It is suitable for use in clinical settings for Thai-speaking cochlear implant patients.

Keywords

quality of life disease-specific questionnaires cochlear implant

Introduction

The global prevalence of hearing impairment is steadily increasing. According to the World Health Organization, more than 1.5 billion people worldwide are currently affected, with projections indicating this number will surpass 2.5 billion by 2050.^1,2 For individuals with sensorineural hearing loss, hearing aids (HAs) are commonly used to amplify sound and support daily communication. However, in cases of severe-to-profound sensorineural hearing loss, HAs often prove insufficient due to their limited amplification capabilities. For these patients, cochlear implantation (CI) remains the only viable option.^3–6

Postoperative follow-up is essential to evaluate the outcomes of CI. Among the most important indicators of success is improvement in the patient’s quality of life, which can be assessed using standardized questionnaires.^7–9 These questionnaires are generally classified into two categories: generic and disease-specific. Although generic instruments provide broad assessments of quality of life, they may not adequately capture the unique experiences and challenges of CI users. In contrast, disease-specific questionnaires are designed to assess quality-of-life domains that are directly influenced by CI use.¹⁰

Cochlear Implant Quality of Life (CIQOL) is a disease-specific quality of life questionnaire developed according to the Patient-Reported Outcomes Information System and COnsensus-based Standards for the Selection of health status Measurement INstruments guidelines (Supplemental Material). The CIQOL-35 Profile was developed directly from user input and provides essential data that reflect users’ needs. It enables specialists to evaluate patients’ quality of life from the patients’ own perspectives. The instrument consists of 35 items across six domain constructs: communication, emotional well-being, entertainment, environment, listening effort, and social functioning.^11–13

Currently, no disease-specific quality-of-life questionnaire is available in the Thai language. Although several generic instruments are used to evaluate CI users and often yield satisfactory results, patients continue to report unmet issues related to their listening experiences—particularly in entertainment and sound enjoyment—which are not adequately addressed by these existing tools. This gap highlights the need to translate and validate such a tool for use in Thai clinical and research settings. Therefore, the objective of this study is to translate and validate the Thai version of the CIQOL questionnaire (CIQOL-Th) for use among Thai-speaking CI recipients.

Method

This study is a cross-sectional study aimed to evaluate the validity and reliability of CIQOL-Th. The study comprised two phases: the translation process and the data collection process, as described below.

Translation

The CIQOL-Th consists of 35 items across six subdomains: communication (10 items), emotional (five items), entertainment (five items), environment (five items), listening effort (five items), and social (five items).

The translation process followed the guideline proposed by Hall et al.¹⁴ It involved forward translation from English to Thai by two independent translators one with a medical background and one without to ensure both clinical accuracy and natural language usage. This was followed by back-translation into English by a separate bilingual translator to assess conceptual equivalence. An expert committee then reviewed all versions and reached consensus on the final Thai translation.

Content validity was evaluated by three experts—one otolaryngologist and two audiologists with direct clinical experience in CI care—using the Index of Item–Objective Congruence (IOC). In addition, 10 healthy participants assessed each item using a five-point Likert scale to rate understanding, reading comprehension, clarity, evaluation, and appropriateness. This assessment was conducted twice with a 2-week interval to ensure that the CIQOL-Th is suitable for use in the Thai CI patient population. Following this process, the finalized CIQOL-Th was administered to CI users for further validation.

Participants and data collection

Data were collected from CI recipients at two tertiary hospitals: Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, and Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University.

Participants included individuals who underwent CI at 18 years of age or older, had used the device for at least 1 year, and received regular postoperative follow-up, including listening and language rehabilitation, by experienced audiologists and otologists. Eligible participants were required to use the Thai language in daily communication and be able to read and write Thai. To minimize participant burden, potential participants were contacted if they had an upcoming clinic appointment. Individuals who did not meet the inclusion criteria or were unable to complete the study procedures were excluded.

Nineteen adult participants were enrolled, with 15 from Srinagarind Hospital and four from Songklanagarind Hospital. Of these, 57.8% were male and 42.2% were female, with ages ranging from 21 to 72 years.

To assess test–retest reliability, all participants completed the CIQOL-Th questionnaire twice, with 2 weeks interval between administrations. Data collection took place between October 2023 and October 2024. Written informed consent was obtained from all participants prior to study enrollment.

Ethics

This study was approved by the Khon Kaen University Ethics Committee for Human Research, Faculty of Medicine, on August 28, 2023 (reference no. HE-661278), and by the Human Research Ethics Committee of the Faculty of Medicine, Prince of Songkla University, on December 15, 2023 (reference no. REC.66-400-196).

Statistical analysis

All statistical analyses were conducted using IBM SPSS Statistics, version 28 (IBM, New York, USA). Descriptive statistics, including means and standard deviations, were used to summarize participants’ general information such as sex and age. Content validity was assessed using the Index of IOC and a five-point Likert rating scale.

Reliability analysis included assessment of internal consistency using Cronbach’s alpha coefficients. Test–retest reliability was evaluated using the intraclass correlation coefficient (ICC), with repeated questionnaire administrations conducted at 2 weeks interval.

The required sample size was calculated using the lowest test–retest reliability coefficient (r = 0.80) reported in the validated original questionnaire.¹² With the significant level of 0.05 and power of 80%, the minimum sample size was 10 participants.¹⁵ This sample size is also consistent with those reported in other questionnaire translation and validation studies.^16–18

Results

Content validity of the CIQOL-Th was assessed by a panel of three experts. Each item in the translated questionnaire was reviewed to ensure linguistic accuracy and cultural appropriateness for the Thai context. As a result, all items achieved an Index of IOC score of 1.0, indicating excellent content validity.¹⁹

Following experts review, the questionnaire was piloted with 10 normal-hearing Thai participants. They were asked to read each item, provide feedback on clarity and comprehension, and rate each item using a five-point Likert scale. The results revealed a mean score of 4.71 and a standard deviation of 0.20 (min = 4.35, max = 5), indicating good comprehension and item relevance across all items²⁰ (Table 1).

Table 1.

Likert rating scale in normal-hearing Thai participants.

Item	Likert score first attempt				Likert score second attempt				Overall
Item	N	Min 1	Max 1	Mean 1	N	Min 2	Max 2	Mean 2	Mean total
Item 1	10	3	5	4.8	10	4	5	4.7	4.75
Item 2	10	4	5	4.5	10	4	5	4.9	4.7
Item 3	10	4	5	4.8	10	4	5	4.7	4.75
Item 4	10	4	5	4.9	10	5	5	5	4.95
Item 5	10	3	5	4.3	10	4	5	4.9	4.6
Item 6	10	4	5	4.7	10	4	5	4.9	4.8
Item 7	10	4	5	4.7	10	4	5	4.9	4.8
Item 8	10	2	5	4.4	10	4	5	4.8	4.6
Item 9	10	1	5	4.2	10	4	5	4.7	4.45
Item 10	10	1	5	4	10	4	5	4.7	4.35
Item 11	10	2	5	4.7	10	5	5	5	4.85
Item 12	10	3	5	4.3	10	5	5	5	4.65
Item 13	10	3	5	4.8	10	5	5	5	4.9
Item 14	10	3	5	4.4	10	4	5	4.7	4.55
Item 15	10	3	5	4.4	10	4	5	4.8	4.6
Item 16	10	2	5	4.6	10	4	5	4.8	4.7
Item 17	10	4	5	4.7	10	5	5	5	4.85
Item 18	10	3	5	4.6	10	5	5	5	4.8
Item 19	10	3	5	4.6	10	4	5	4.9	4.75
Item 20	10	4	5	4.8	10	5	5	5	4.9
Item 21	10	4	5	4.9	10	4	5	4.9	4.9
Item 22	10	3	5	4.3	10	4	5	4.7	4.5
Item 23	10	3	5	4.7	10	4	5	4.9	4.8
Item 24	10	3	5	4.5	10	4	5	4.9	4.7
Item 25	10	4	5	4.9	10	4	5	4.9	4.9
Item 26	10	2	5	3.6	10	4	5	4.7	4.15
Item 27	10	3	5	4.3	10	4	5	4.8	4.55
Item 28	10	4	5	4.9	10	5	5	5	4.95
Item 29	10	3	5	4.5	10	4	5	4.8	4.65
Item 30	10	3	5	4.5	10	4	5	4.9	4.7
Item 31	10	2	5	4	10	4	5	4.5	4.25
Item 32	10	5	5	5	10	5	5	5	5
Item 33	10	4	5	4.9	10	5	5	5	4.95
Item 34	10	4	5	4.9	10	5	5	5	4.95
Item 35	10	4	5	4.5	10	4	5	4.8	4.65
All items	10	1	5	4.56	10	4	5	4.86	4.71

A total of 19 CI users participated in the study. Their demographic and clinical characteristics are presented in Table 2.

Table 2.

Demographic data of CI-adult group.

Gender	Percentage (n)
Male	57.8 (8)
Female	42.2 (11)
Age	Mean (years) ± SD (min–max)
Current age	54.32 ± 15.571 (21–72)
Age at time of surgery	47.79 ± 14.081 (19–69)
Duration of cochlear implant use	6.53 ± 4.948 (1–15)
Education level	Percentage (n)
Below bachelor’s degree	10.5 (2)
Bachelor’s degree	52.6 (10)
Master degree	31.5 (6)
Vocational certificate	5.2 (1)
Monthly income (Baht)	Percentage (n)
No income	10.5 (2)
10,000–29,999	36.8 (7)
30,000+	52.6 (10)

CI: cochlear implantation.

In the CI-adult group, the CIQOL-Th demonstrated good internal consistency across all six subdomains, with Cronbach’s alpha values exceeding 0.6. Test–retest reliability was also acceptable, with most subdomains showing ICCs > 0.7. However, two subdomains—communication and listening effort—showed lower test–retest reliability, with ICC values of 0.512 and 0.426, respectively (Table 3).

Table 3.

Internal consistency and test–retest reliability in CI-adult.

CIQOL-adult	Cronbach’s alpha (first, second attempt)	Intraclass correlation coefficient (r)
CIQOL-total	0.955 (0.931, 0.971)	0.887
Communication (items 1–10)	0.880 (0.832, 0.913)	0.512
Emotional (items 11–15)	0.862 (0.833, 0.890)	0.778
Entertainment (items 16–20)	0.915 (0.919, 0.914)	0.905
Environment (items 21–25)	0.867 (0.843, 0.889)	0.745
Listening effort (items 26–30)	0.677 (0.573, 0.787)	0.426
Social (items 31–35)	0.918 (0.936, 0.90)	0.861

CI: cochlear implantation; CIQOL: Cochlear Implant Quality of Life.

Discussion

The CIQOL-Th was developed through a rigorous cross-cultural translation process based on Hall et al.’s guidelines, ensuring both linguistic accuracy and cultural relevance while preserving the original intent of each item. This approach was consistent with previous cross-cultural translation studies.^16,18

At least two language experts independently translated the original instrument into their native language. The translated versions were then back-translated into English by different expert translators, followed by a committee review in which the translations were jointly evaluated and finalized.

Almost all items posed no obstacles during the translation process; only one item (Item 26) presented ambiguity in the Thai context. The original wording, “I am able to follow a conversation with minimal effort,” indicates that only a small amount of effort is required to listen. However, when translated into Thai, this phrase could be interpreted ambiguously, either as having to make an effort to listen or not having to make an effort to listen, potentially causing confusion among readers. Therefore, during the committee review, this item was revised to improve clarity and readability while preserving the original meaning. This revision ensured that respondents could clearly understand the item independently, whereas all other items were readily comprehensible within the Thai linguistic context.

The finalized questionnaire was subsequently field-tested in two groups: three experts and a group of healthy participants, prior to administration to CI recipients. In contrast, the French and German studies evaluated readability and comprehension of the finalized questionnaire directly in the target population. Nevertheless, in this study, the questionnaire was administered to CI recipients to assess internal consistency and test–retest reliability.

The Thai version demonstrated strong content validity, supported by an IOC score of 1.0 for all items, as evaluated by three experts. Preliminary testing with 10 healthy participants also yielded high mean Likert-scale scores (overall mean = 4.71; range = 4.1–5.0), indicating good clarity and acceptability of the translated items and supporting their suitability for use in the Thai CI population.

The CIQOL-Th demonstrated strong internal consistency across most subdomains (Cronbach’s alpha = 0.880–0.955). Only the listening effort subdomain showed acceptable internal consistency (α = 0.677). These findings are consistent in validation studies of the original instrument, thereby supporting the reliability of the Thai version for use in adult CI users.¹²

Test–retest reliability was excellent for most subdomains (r = 0.861–0.905). However, four subdomains demonstrated lower stability: environment and emotion showed acceptable test–retest reliability (r = 0.745 and 0.778, respectively), whereas communication and listening effort exhibited poor test–retest reliability (r = 0.512 and 0.426, respectively).

These findings may be attributable to several factors. First, the wide age range of participants (21–72 years) may have introduced variability in mental and emotional states, leading to fluctuations in responses between the two administrations. For example, working-age participants may experience greater occupational stress and hold higher expectations regarding listening performance than retired individuals, potentially influencing scores in certain subdomains. Second, despite strict adherence to cross-cultural translation guidelines, cultural nuances may have resulted in unintended interpretations of some items. Although efforts were made to preserve the original meaning, certain questions may not fully align with the Thai cultural context, which could have affected comprehension and response consistency, thereby contributing to reduced test–retest reliability.

This study has several strengths. First, it is the first to translate and validate a disease-specific quality of life questionnaire for CI users in the Thai language, addressing an important gap in clinical assessment tools available for Thai-speaking populations. Second, the rigorous translation process, based on established cross-cultural guidelines, ensured both linguistic and conceptual equivalence of the instrument. Lastly, the study included adult CI users across two major tertiary hospitals in Thailand, enhancing the diversity and representativeness of the sample.

We acknowledge that the overall sample size was small; however, rigorous sample size calculations confirmed that the number of participants was sufficient for the scope of this preliminary study. In addition, our sample size is consistent with those reported in previous questionnaire translation studies.^16–18 To further strengthen the reliability and validity of the CIQOL-Th, future studies should assess construct validity and include a larger study population.

Conclusion

The CIQOL-Th is a valid and reliable instrument for assessing quality of life in adult CI users. It is appropriate for use in clinical settings to evaluate patient-reported outcomes among Thai-speaking CI recipients.

Supplemental Material

sj-docx-1-smo-10.1177_20503121261423634 – Supplemental material for The validity and reliability of the Thai version of the Cochlear Implant Quality of Life questionnaire

Supplemental material, sj-docx-1-smo-10.1177_20503121261423634 for The validity and reliability of the Thai version of the Cochlear Implant Quality of Life questionnaire by Sirawat Srichandr, Panida Thanawirattananit, Viraporn Atchariyasathian and Patorn Piromchai in SAGE Open Medicine

Supplemental Material

sj-docx-2-smo-10.1177_20503121261423634 – Supplemental material for The validity and reliability of the Thai version of the Cochlear Implant Quality of Life questionnaire

Supplemental material, sj-docx-2-smo-10.1177_20503121261423634 for The validity and reliability of the Thai version of the Cochlear Implant Quality of Life questionnaire by Sirawat Srichandr, Panida Thanawirattananit, Viraporn Atchariyasathian and Patorn Piromchai in SAGE Open Medicine

Footnotes

Acknowledgements

This study would not have been possible without the generous participation of the cochlear implant recipients and the dedicated support of the clinical and research staff at Khon Kaen University and Prince of Songkla University,

ORCID iD

Patorn Piromchai

Ethical considerations

Institutional Review Board Statement: The study complied with the Declaration of Helsinki, was approved by the Ethics Committee of Khon Kaen University’s Faculty of Medicine on August 28, 2023 (HE.661278), Ethics Committee of Prince of Songkla University’s Faculty of medicine on December 15, 2023 (REC.66-400-19-6) and registered with the Thai Clinical Trials Registry (TCTR-20230918004).

Author contributions

Sirawat Srichandr: conducted the study, including data collection, data analysis, and drafting of the article. Patorn Piromchai: supervised the study, contributed to study design, critically revised the article. Panida Thanawirattananit: coordinate, supervised the study, provided academic supervision and methodological support at Khon Kaen University. Viraporn Atchariyasathian: provided academic supervision and methodological support at Songkhla University.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study granted by Health Systems Research Institute (HSRI) of Thailand (ID: 67-004).

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Institutional Review Board Statement: The study complied with the Declaration of Helsinki, was approved by the Ethics Committee of Khon Kaen University’s Faculty of Medicine on August 28, 2023 (HE.661278), Ethics Committee of Prince of Songkla University’s Faculty of medicine on December 15, 2023 (REC.66-400-19-6) and registered with the Thai Clinical Trials Registry (TCTR-20230918004).

Supplemental material

Supplemental material for this article is available online.

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