Downloaded from http://journals.lww.com/ear-hearing by rAQMxwvowtrwClbjGR0UGEWdH7hoo2lhwFes0l31KkQZBj+X+XSt+PRthgzv0mzkGWNgpM5Krd8UAfjfop1bJ2tB62JwKFNOrHSJes9M4WgJM9POXaKEEKl/zHFT/PGbkFP5f7pYRkwX5/DGHjS49rbXMv9AwfFhq61yjl1f9RU3xV8xDbHOSw== on 06/27/2018 Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. <zdoi; 10.1097/AUD.0000000000000522> 0196/0202/2018/394-656/0 • Ear & Hearing • Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved • Printed in the U.S.A. 656 Objectives: This study determined the effect of hearing loss and English- speaking competency on the South African English digits-in-noise hear- ing test to evaluate its suitability for use across native (N) and non-native (NN) speakers. Design: A prospective cross-sectional cohort study of N and NN English adults with and without sensorineural hearing loss compared pure- tone air conduction thresholds to the speech reception threshold (SRT) recorded with the smartphone digits-in-noise hearing test. A rating scale was used for NN English listeners’ self-reported competence in speak- ing English. This study consisted of 454 adult listeners (164 male, 290 female; range 16 to 90 years), of whom 337 listeners had a best ear four- frequency pure-tone average (4FPTA; 0.5, 1, 2, and 4 kHz) of ≤25 dB HL. Results: A linear regression model identified three predictors of the digits-in-noise SRT, namely, 4FPTA, age, and self-reported English- speaking competence. The NN group with poor self-reported English- speaking competence (≤5/10) performed significantly (p < 0.01) poorer than the N and NN (≥6/10) groups on the digits-in-noise test. Screening characteristics of the test improved with separate cutoff values depend- ing on English-speaking competence for the N and NN groups (≥6/10) and NN group alone (≤5/10). Logistic regression models, which include age in the analysis, showed a further improvement in sensitivity and specificity for both groups (area under the receiver operating character- istic curve, 0.962 and 0.903, respectively). Conclusions: Self-reported English-speaking competence had a sig- nificant influence on the SRT obtained with the smartphone digits-in- noise test. A logistic regression approach considering SRT, self-reported English-speaking competence, and age as predictors of best ear 4FPTA >25 dB HL showed that the test can be used as an accurate hearing screening tool for N and NN English speakers. The smartphone digits- in-noise test, therefore, allows testing in a multilingual population famil- iar with English digits using dynamic cutoff values that can be chosen according to self-reported English-speaking competence and age. Key words: Digits-in-noise, Hearing loss, Hearing screening, Hearing test, Smartphone, Speech-in-noise. (Ear & Hearing 2018;39;656–663) INTRODUCTION An important part of maintaining health and well-being for older adults is to screen for and treat hearing loss (Bushman et al. 2012). Nevertheless, adult hearing screening programs are very scarce. Hearing screening tests will become increasingly important as the adult population is continuously growing and life expectancy escalates. It is expected that the world’s adult population aged 60 years and older will almost double from 12% to 22% by 2050 (World Health Organization 2015). The incidence of hearing loss increases as the adult population ages with approximately one-third of adults aged 65 years and older affected by a disabling hearing loss (World Health Organization 2013). The latest Global Burden of Disease study (Global Bur- den of Disease 2016) indicates that 1.33 billion people suffer from hearing loss, making it the second most common impair- ment evaluated. Unfortunately, only about 20% of adults with hearing loss seek help (Smits et al. 2006; Davis et al. 2007). An untreated hearing loss negatively impacts communica- tion abilities and cognitive, physical, and psychological func- tioning and general quality of life (Nachtegaal et al. 2009; Lin 2011; Davis et al. 2016). Communication diffculties related to hearing loss can lead to poor social engagement resulting in restricted socialization, impaired relationships with friends and family with loneliness as a consequence, especially in the elderly (Davis et al. 2016). Persons with hearing loss demon- strate greater cognitive decline that may be associated with an increased risk of dementia (Lin 2011; Lin & Ferrucci 2012; Davis et al. 2016). Hearing loss is also related to physical impairment in older adults with an increased likelihood to fall due to impaired auditory and vestibular cues that limit envi- ronmental awareness, attention, and postural control (Lin & Ferrucci 2012). The communication, physical, and cognitive effects of hearing loss have also been linked to psychological impairments and feelings of depression, anxiety, frustration, and fatigue resulting in poor quality of life (Davis et al. 2007). The physical impairments associated with a hearing loss can furthermore cause an added fnancial burden on the elderly due to increased healthcare costs (Simpson et al. 2016). Early hearing loss intervention and counseling are impor- tant services that may prevent or forestall cognitive decline, dementia, and the negative psychological and physical effects associated with hearing loss and save future health-related costs (Simpson et al. 2016). Hearing screening programs are important for early detection of hearing loss to maximize hear- ing rehabilitation and quality-of-life outcomes. Various hear- ing screening tests exist, of which standard hearing screening options usually include self-administered questionnaires and pure-tone audiometry. Self-administered questionnaires are an affordable method to detect hearing loss and could be uti- lized by any healthcare professional (Swanepoel et al. 2013). In recent years, more accessible hearing screening methods have been developed, which individuals can access directly without a healthcare professional. Many countries including the Nether- lands, United States, Australia, Germany, Poland, Switzerland, and France now offer landline telephone hearing screening tests The South African English Smartphone Digits-in-Noise Hearing Test: Effect of Age, Hearing Loss, and Speaking Competence Jenni-Marí Potgieter, 1 De Wet Swanepoel, 1–3 Hermanus Carel Myburgh, 4 and Cas Smits 5 1 Department of Speech-Language Pathology and Audiology, University of Pretoria, South Africa; 2 Ear Sciences Centre, School of Surgery, University of Western Australia, Nedlands, Australia; 3 Ear Science Institute Australia, Subiaco, Australia; 4 Department of Electrical, Electronic and Computer Engineering, University of Pretoria, Pretoria, South Africa; and 5 Department of Otolaryngology – Head and Neck Surgery, Section Ear and Hearing, and Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands.