ECHO-ADL: An image-based questionnaire for assessing hearing-specific activities of daily living (ADL) in people with hearing loss

The aim of this study is to develop and validate an image-based questionnaire assessing hearing-specific activities of daily living (ADL) in people with hearing loss, the ECHO-ADL. The motivation for developing a hearing-specific ADL questionnaire arises from evidence that individuals with hearing loss experience greater difficulties in activities of daily living (ADL) than those without hearing loss (Assi et al., 2024; Dalton et al., 2003; Gopinath et al., 2012). However, common ADL scales do not take auditory limitations into account. Consequently, many individuals with hearing loss find it difficult to relate to the situations described in conventional ADL scales, or the tasks most relevant to their daily challenges are not represented. Therefore, there is a clear need for a tool that reflects the everyday realities of people with hearing loss and allows for a more accurate assessment of hearing-related functional limitations. In response to this need, the ECHO-ADL will be developed as a graphically supported questionnaire designed to capture hearing-specific everyday difficulties. It is intended to describe the current status of everyday functioning, as well as to monitor therapy outcomes. The picture‑based format has the advantage of facilitating easier translation of the items into other languages and also enables participation by individuals with language impairments or intellectual disabilities. The target population of this study includes adults aged 18 years and older, both with and without hearing impairment, covering a broad range of hearing abilities. Methodologically, the study will begin with a comprehensive literature review and the identification of potential questionnaire items. Individuals with hearing loss will help select relevant items. Based on participant feedback, the final questionnaire including its graphical components will be designed. To validate the ECHO-ADL, participants will complete a neuropsychological test battery to assess cognitive functioning, along with questionnaires measuring subjective hearing perception, everyday competencies, hearing-related quality of life and depressive symptoms. To evaluate test–retest reliability, the ECHO-ADL will be administered again approximately six months later. Data will be analyzed to evaluate the reliability and validity of the ECHO-ADL and to examine its relationship with hearing-related and psychological outcomes. Internal consistency will be assessed using Cronbach’s alpha. Test–retest reliability over approximately six months will be examined. Construct validity will be evaluated by factor analysis to investigate the underlying factor structure of the ECHO-ADL. Convergent validity will be tested by calculating correlations between ECHO-ADL scores and measures of subjective hearing perception, everyday functioning, hearing-related quality of life and depression. Discriminant validity will be examined by comparing ECHO-ADL scores between participants with and without hearing loss and between subgroups with different levels of hearing impairment. To further explore group differences, analyses of variance (ANOVAs) will be conducted, for example across hearing loss severity groups or age groups. Additional, analysis of covariance (ANCOVA) models may be applied to control for potential confounders such as age, sex or education. We expect the following outcomes: Higher ECHO-ADL difficulty scores will be associated with lower hearing-related quality of life. Higher ECHO-ADL difficulty scores will be associated with poorer everyday skills as assessed by established ADL measures. People with hearing loss will report significantly more ECHO-ADL difficulties than people without hearing loss. Within the group of people with hearing loss, those with more severe hearing loss will report more ECHO-ADL difficulties than those with mild hearing loss.