Noise exposure is central to hearing impairment, especially for adolescents. Chinese youth frequently and consciously expose themselves to loud noise, often for many hours. Hence, a Chinese-adapted evaluative scale to measure youth's attitude toward noise could rigorously evaluate data validity and reliability. After authenticating the youth attitude to noise scale (YANS) originally developed by Olsen and Erlandsson, we purposively sampled and surveyed 642 freshmen at Capital Medical University in Beijing, China. To establish validity, we conducted confirmatory factor analysis according to Olsen's classification. To establish reliability, we calculated Cronbach's alpha coefficient and split-half coefficient. We used Bland-Altman analysis to calculate the agreement limits between test and retest. Among 642 students, 550 (85.67%) participated in statistical analysis (399 females [72.55%] vs. 151 males [27.45%]). Confirmatory factorial analysis sorted 19 items into four main subcategories (F1-F4) in terms of factor load, yielding a correlation coefficient between factors <0.40. The Cronbach's alpha coefficient (0.70) was within the desirable range, confirming the reliability of Chinese-adapted YANS. The split-half coefficient was 0.53. Furthermore, the paired t-test reported a mean difference of 0.002 (P = 0.9601). Notably, the mean overall YANS score (3.46) was similar to YANS testing in Belgium (3.10), but higher than Sweden (2.10) and Brazil (2.80). The Chinese version of the YANS questionnaire is valid, reliable, and adaptable to Chinese adolescents. Analysis of the adapted YANS showed that a significant number of Chinese youth display a poor attitude and behavior toward noise. Therefore, Chinese YANS can play a pivotal role in programs that focus on increasing youth awareness of noise and hearing health.
Keywords: Chinese adaption, confirmatory factorial analysis, reliability, validity, youth attitude to noise scale
|How to cite this article:|
Zhu X, Bihi A, Hu X, Lv Y, Abbas A, Zhu X, Mo L, Peng X. Chinese-adapted youth attitude to noise scale: Evaluation of validity and reliability. Noise Health 2014;16:218-22
|How to cite this URL:|
Zhu X, Bihi A, Hu X, Lv Y, Abbas A, Zhu X, Mo L, Peng X. Chinese-adapted youth attitude to noise scale: Evaluation of validity and reliability. Noise Health [serial online] 2014 [cited 2020 Sep 27];16:218-22. Available from: http://www.noiseandhealth.org/text.asp?2014/16/71/218/137055
| Introduction|| |
Disabling hearing impairment refers to impairment >40 dB in the better hearing ear in adults and >30 dB in the better hearing ear in children. According to the World Health Organization, more than 360 million people (5%) worldwide (i.e., 328 million adults and 32 million children) have disabling hearing impairment.  Most of these people live in low- and middle-income countries. Moreover, approximately one-third of people older than 65 years of age, most living in South Asia, Asia Pacific, and sub-Saharan Africa, have a disabling hearing loss. For example, a national sample survey on hearing disability in China shows that 27.8 million Chinese citizens suffer from hearing impairment; 30,000 have hearing impairment from birth.  Today, China is not only the world's fastest developing country, but it also has one of the fastest growing "aging populations." , Therefore, hearing impairment is an increasingly serious health crisis in China and worldwide. Because half of all cases of hearing loss are avoidable through primary prevention,  it is imperative to understand the cause of hearing disability. However, it is very difficult to differentiate between exact and general causes. 
Noise exposure is central to hearing impairment, especially for adolescents.  Although short periods of amplified sound do not cause hearing impairment, chronic exposure results in cumulative damage.  The growing popularity of Western culture (i.e., pop music, cinemas, and loud parties) among Chinese youth results in frequent and conscious exposure to loud noise, often for many hours.  In addition, the fusion of social practices (e.g., Karaoke TV (KTV), personal audio systems, and electronic gaming centers) that include amplified sound is without a doubt an existing but often ignored phenomenon.  Moreover, noise pollution from industry, construction, and transportation has become increasingly prominent in China during the past two decades. , Hence, constant exposure to loud noise is a serious health hazard that requires the development of tools to control, identify, and prevent hearing impairment.
The youth attitude to noise scale (YANS), an effective instrument developed by Widén and Erlandsson,  was used in Sweden, Brazil,  and USA.  YANS consists of 19 items assessed on a 5-point Likert scale that ranges from "totally disagree" to "totally agree." However, due to differing social and cultural conditions, a universal questionnaire is impractical in assessing youth's attitude towards noise. Cross-cultural adaptation of YANS must encompass both language (translation) and culture.  Moreover, validated questionnaire translation demands linguistic terms that properly reflect a population's social and cultural conditions. Therefore, a country's unique beliefs and habits require psychometric measures that reflect its culture.
In China, hearing impairment is evolving into a signiﬁcant social and public health problem. Because the original YANS questionnaire is not completely compatible with the Chinese population for the aforementioned reasons, it is necessary to create an adapted scale to evaluate youth's attitude toward noise that can demonstrate its properties through measurement and rigorous evaluation of its validity and reliability. A Chinese adaption of YANS will help identify the level of information regarding noise exposure in Chinese youth as well as their own perceptions and behavior regarding noise and essentially seek a proper instrument to interoperate these findings.
| Methods|| |
Authentication of the youth attitude to noise scale questionnaire
Widén and Erlandsson developed YANS,  and Zocoli et al. translated YANS into the Portuguese language.  Widén et al. translated YANS for use in the USA.  The most commonly used YANS version contains 19 items that reflect four issues:
- Attitudes toward noise associated with youth culture,
- Attitudes associated the ability concentrate in noisy environments,
- Attitudes concerning day-to-day noises, and
- Attitudes that influence the sound environment [Annex 1, original version of YANS]. All answers are based on a 5-point Likert scale ranging from 1 (fully disagree) to 5 (fully agree). In the Chinese adaptation discussed here, we score some items (Nos. 2, 5, 6, 8, 9, 10, 11, 14, and 17) inversely (i.e., score 5 = score 1). A low score implies a more negative attitude toward noise and a high score implies a more positive attitude towards noise.
Authentication of YANS involved many intricacies and stages. First, a three-member team, including a foreign language expert, an audiologist, and a linguist, translated the questionnaire from English to Chinese. Next, an audiologist proficient in written communication between Chinese and English conducted counter-translation. A thorough comparison of both versions identified minimal differences and determined that the translated version did not hinder the validity of the questionnaire. Finally, a group of experts approved the Chinese YANS [Annex 2, Chinese-adapted version of YANS].
Validity assessment of YANS content considered the difference between Western and Chinese culture and their adherent social environment. Six audiologists from Key Laboratory of Otolaryngology Head and Neck Surgery, Capital Medical University (CMU), and the Ministry of Education rated each item according to its relevance to Chinese culture. Using a 4-point scale where 1 is "fully irrelevant" and 4 is "fully relevant," we calculated the relevancy of each item according to the item-level content validity index (number of scores given divided by number of experts). For the scale-level content validity index, we calculated the percentages of each item's score by each expert divided by number of experts. In the original YANS, items 1, 4, 9, and 12 received a poor score from all of our experts. Therefore, we conducted an in-depth interview among 10 freshmen students, who agreed that the above-mentioned items (discos, rock concert, dances, sporting event) were not of social norm. Consequently, we replaced those items with items that are more common in China (i.e., KTV, cinema, food court, and gaming centers), further altering the questionnaire.
To provide a fair consensus, we purposively sampled freshman students at CMU, which attracts students from across China. Inclusion criteria for the study comprised being a freshman student of either gender, aged between 16 and 20 years. All participants were studying medicine, public health, or nursing at CMU. The Institutional Review Board and the Ethics Committee at CMU approved our study protocol.
Initially, researchers contacted university officials to inform them about the procedural implementation of the questionnaire. Because enrollment at CMU requires a physical and health examination, it made sense to include an evaluative questionnaire as part of their health checkup. Hence, the nonresponse rate was minimal. We invited 19 monitors from 19 classes (freshman students) to participate in an orientation to the questionnaire and informed them about each item on the questionnaire, its content, and purpose. After attaining complete understanding of the questionnaire, monitors distributed the questionnaire to their respective classes. To avoid any misunderstanding, a research team member accompanied monitors while they explained the questionnaire to their classmates. Participants were asked to complete the questionnaire by themselves in <20 min.
Using Epidata 3.0 (The EpiData Assocoation, Odense Denmark), independent research team members doubly input raw data into a customized database. All data was checked and modified before statistical analysis. To establish the questionnaire's validity, confirmatory factor analysis was carried out according to Olsen's classification. We also compared our study with papers on YANS published previously in Sweden, USA, and Brazil. Retrospectively, we used a chart to compare the four factors and their correlation with other countries. To establish reliability, we calculated Cronbach's alpha coefficient and split-half coefficient. In addition, we conducted a Student's t-paired test to check for mean differences between test and retest during normal data distribution. Otherwise, Wilcoxon Rank-Sum test should be performed. At the same time, we used the Bland-Altman test to calculate agreement limits between the test and retest. We conducted all analyses using SAS version 9.0 (SAS Institute Inc. Kary, NC, USA) and Medcal Statistical Software version 13.0.6 (MedCalc Software bvba, Ostend, Belgium) and considered the results of statistical tests significant at 5%.
| Results|| |
Among 642 questionnaires, 14 (2.18%) were not returned. After removing incomplete questionnaires, our final study group included 550 (85.67%) 16-20 years old participants. To test the reliability of retest, we randomly sampled 85 students in three classes after 45 days and asked them to retake the YANS. Data analyses were based on 550 thoroughly examined and completed questionnaires. Among 550 respondents, females (399/72.55%) outnumbered males (151/27.45%).
With the aid of confirmatory factorial analysis, we divided factors into four main subcategories (F1-F4) and arranged questions in terms of each factor [Table 1]. F1 (questions 1, 4, 6, 8, 9 and 12) comprised attitudes regarding noise associated with youth culture. F2 (questions 10, 11, 17 and 18) included attitudes concerning day-to-day noises. F3 (questions 2, 7, 15 and 19) comprised noise and concentration, and F4 (questions 3, 5, 13, 14 and 16) included attitudes that influence the sound environment. Interestingly, the higher the factorial load, the better we understand the significance of the variable.
The correlation coefficients between factors were <0.40 [Table 2]. In addition, the correlation coefficient between the factors and total YANS was more than 0.50. Regarding the internal reliability of Chinese-adapted YANS, Cronbach's alpha coefficient (0.70) was within the desirable range of acceptance. Meanwhile, F1 shows the highest Cronbach's alpha (0.67), which decreased consistently throughout the other factors (F2, F3, F4). On the other hand, the split-half coefficient was 0.53. Furthermore, we performed the Bland-Altman test to test the reliability between test and retest [Figure 1]. The paired t-test reported a mean difference of 0.002 (P = 0.9601) (95% confidence interval [0.67-0.67]) [Figure 1].
In comparison to previously published data, the mean overall YANS score in the Chinese adaptation was similar to YANS testing in Belgium (3.10), but higher than Sweden (2.10) and Brazil (2.80). Moreover, there is a gender related statistically significant difference concerning factor 2, showing more positive attitude toward day-to-day noises among females compared with males [Table 3]. To fully appreciate the global commonalities of YANS, [Table 4] illustrates the variables that remain the same in each factor versus different countries and highlights the variables that change in respective countries (i.e., Sweden, Brazil, USA, and China).
|Table 3: Factors and total YANS: Mean and standard deviation according to gender|
Click here to view
| Discussion|| |
The YANS questionnaire was conducted in several countries, including Sweden, USA, and Brazil. ,, The present study reports the first adaption of YANS for Chinese youth. The development of a culturally adaptive questionnaire is significant because China has unique social, economic, and cultural practices.  Nonetheless, our study indicates that the Chinese version of YANS is valid and reliable (general index a = 0.70), similar to earlier results in USA (0.82) and Brazil (0.75). , In addition, our results show a high level of agreement between test and retest (95% CI: −0.67, 0.67).
The distribution of four factors in our factorial analysis differs slightly from previously published YANS studies [Table 4]. In factor 1 (i.e., attitudes concerning noise associated with youth's cultural aspects), questions 1, 4, 9, 12 were common variables in all YANS studies. In the Chinese version, researchers amended these questions to attain cultural acceptance. , The amended items included KTV, cinema, food court, and gaming centers.
In factor 2 (attitudes day-to-day noises), all participants responded negatively regarding traffic noises, irrespective of country or culture. However, compared to other countries, Chinese youth ignored noise induced by electronic appliances (i.e., refrigerators, fans, computers, etc.). Moreover, our analysis revealed that the average score for factor 2 (M = 3.60) was more positive in China compared to other countries.
In factor 3 (noise and concentration) and factor 4 (skill to influence the sound environment), our results show a starkly different response by Chinese youth compared to youth in other countries. Chinese adolescents showed the most positive attitude toward noise [Table 3]. In other words, they are less troubled (i.e., more tolerant) by the consequences of noise. Notably, the mean overall YANS score (3.46) in our study was similar to Belgium (3.10)  but higher than Sweden (2.10)  and Brazil (2.80),  possibly due to the lack of public awareness programs in China. Consequently, Chinese youth have very limited knowledge about the effects of noise, cultural differences, and the popular stigma that hearing impairment occurs only in the elderly. We also hypothesize that Chinese youth are more introverted, usually tolerant, and often apprehensive about taking action. 
A limitation to our study is that our sample was purposive, not random. Although the difference between average YANS scores of both genders was not statistically significant, our study population included more females than males (399 [72.55%] vs. 51 [27.45%], respectively). In addition, we replaced items such as "discos, dances, rock concerts" by "karaoke, cinema, food court, etc." which might induce the potential incomparability between different sources of recreational noise exposure.
Therefore, further validation of the Chinese YANS questionnaire and incorporating it with other studies will require additional investigation. In particular, items in F3 and F4 need to be improved and changed more explicitly for Chinese youth. For example, items like "I am prepared to do something to make the school environment quieter" need to clarify the meaning of "something." Additionally, what is the definition of "quiet"? Although these questions may be sufficient elsewhere, they lack clarity in Chinese culture. Nonetheless, we hope the information presented here will help hearing programs and national health organizations address noise exposure and recognize the importance of attitude and its relationship to hearing health.
| Conclusion|| |
The Chinese version of YANS questionnaire is valid, reliable, and adaptable to Chinese adolescents. Our analysis shows that a significant number of Chinese youth have a poor attitude and behavior toward noise. Despite symptoms of hearing discomfort, they perceive noise as a positive phenomenon. Therefore, China must develop programs to educate youth on the potential implications of noise exposure. Chinese YANS can play a pivotal role in programs that focus on assessing and implementing a healthy lifestyle for Chinese youth.
| Acknowledgment|| |
The authors thank scientific editor Karen Williams (Kwills Editing Services, Weymouth, MA, USA) for English-language editing.
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Dr. Xiaoxia Peng
No. 10 Xitoutiao, You An Men, Beijing 100069
Source of Support: This study was supported by the Importation and Development of High-Caliber Talents Project of Beijing Municipal Institutions (CIT&TCD201304189). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript,, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]