Abstract
Objectives: To report the development and administration of the Saudi pediatric speech intelligibility (SPSI) test.
Methods: This study was carried out at King Abdullah Ear Specialist Center, King Saud University, Riyadh, Saudi Arabia, between 2021 and 2023. A pilot study was carried out in 5 regions of Saudi Arabia including 100 normal hearing children aged 7-11 years old, with 20 children from each region. The final test materials were voice-recorded by a native Saudi radio announcer, and a software-based application for administering the SPSI was developed.
Results: During the pilot study, minor adjustments were carried out to the test for more clarity. The developed SPSI software is an android-based application that includes features like automatic result calculation, data saving, and individual user accounts for examiners to review results. The SPSI test comprises 4-word cards and 2 sentence cards, each with 5 pictures, and operates in 3 modes: quiet, background noise, and competing sentences.
Conclusion: The SPSI test has been developed in an android-based software using the Saudi local dialects. It can facilitate comprehensive and accurate assessment of speech intelligibility, particularly in children with hearing impairments.
Production, recognition, and understanding of speech is an important factor in the development of children. While pure tone audiometry is an essential tool for evaluating basic auditory perception, the assessment of speech intelligibility provides a more comprehensive evaluation of hearing in children, especially in those with hearing loss. Speech intelligibility testing allows one to assess the state and trajectory of language development. In clinical settings, such testing can be used to measure the effectiveness of interventions such as hearing devices and rehabilitation.1 When clinically evaluating speech recognition, a number of factors should be considered, such as the listener’s level of language proficiency, listeners diversity, language differences between the speaker and the listener, the presence of visual cues, and other environmental factors such as the impact of background noise.2
Assessment of speech recognition in children involves evaluating their ability to perceive, process, and comprehend spoken language. Speech sound discrimination, word and sentence recognition, and speech intelligibility testing are all among the options to assess speech recognition. Currently, there are several tests in use to assess the speech intelligibility with different advantages such as early speech perception test, meaningful auditory integration scale (MAIS), infant-toddler (IT)-MAIS, and the pediatric speech intelligibility (PSI) test.3-6 The PSI test was originally published in 1984 by Jerger et al.6 It is a widely used and well validated speech intelligibility test which is specifically designed for use with young children. Its design allows for the evaluation of both auditory closure and binaural separation.6,7 It has been successfully translated into several language including Arabic and Mandarin, demonstrating that the test efficacy is not fundamentally dependent upon English phonology, morphology, or syntax.8,9
Arabic is not a monolithic language; rather, it is composed of numerous local dialects (AMMIYA) which have varying degrees of mutual intelligibility. In everyday speech, these dialects are used almost exclusively, while modern standard Arabic (MSA, known in Arabic as FUSHA) is generally reserved for more formal settings, or for when dialect differences impede mutual intelligibility between speakers.10 In our clinic, speech audiometry is currently carried out with the Arabic phonetically balanced words test developed at Ain Shams University in Egypt.11 This test, although functional, is not entirely suitable due to differences in the Arabic language dialects spoken in Egypt and Saudi Arabia. These differences might potentially cause confusion during speech intelligibility testing, especially in children with hearing impairments.
This imposes some limitations on our ability to carry out effective clinical speech perception testing. In some of our previous publications, reviewers noted that the lack of fully appropriate speech audiometry testing material may have imposed limitations on the conclusions we could draw from our work. In the light of these concerns, we have developed a speech intelligibility test specifically tailored for use among speakers of the Saudi Arabic dialect. In this report, we first outline the design and development of the Saudi pediatric speech intelligibility (SPSI) test. We then presented the findings from a pilot study in which it was administered to 2 cohorts of pediatric listeners. Finally, we discussed the clinical significance of this test.
Methods
This prospective cohort study was carried out at King Abdullah Ear Specialist Center, Riyadh, Saudi Arabia between 2021 and 2023. The institutional review board at the College of Medicine, King Saud University, Riyadh, Saudi Arabia, approved the study under the approval number: E-24-8683.
Saudi pediatric speech intelligibility test development proceeded according to the following stages: I) adaptation of the Egyptian PSI test (Figure 1); II) word and sentence selection: with the help of a Saudi dialect professional, the original words of the test were modified to their Saudi Arabic linguistic and cultural equivalents (Table 1). While selecting the test words, we took into consideration that Saudi Arabia has a variety of local dialects, meaning that each region may have different pronunciations or different words for the same concept; III) image selection: to develop the corresponding images, a graphic design professional was consulted and provided images. Importantly, most of the pictures were chosen as real ones and arranged in pyramidal shape. This arrangement was selected to enhance the visual coherence and engagement with the test materials; and IV) review of the initial draft of the test materials including words, sentences, and pictures.
- Schematic diagram depicting the development of the Saudi pediatric speech intelligibility test.
- Example of Arabic and English texts of the Saudi pediatric speech intelligibility sentences.
This pilot study aimed to validate the initial draft of the test material. The study was carried out in 5 regions (Central, South, North, West, and East) of Saudi Arabia. From each region, 20 children aged 7-11 years old with normal hearing were recruited through their schools (N=100, 60 male and 40 female). In each region, each picture (such as a cat, house, and mouse) was displayed to the main citizens of the area, mainly in schools. Each participant has been instructed to identify the objects in the pictures by asking them “what is the name of this object?”
If the participants from all 5 regions agreed on the name of the object shown in the picture, the photo was accepted for inclusion in the test material. If different names were used in different dialect regions, the most commonly used word was selected. In other words, the used materials are all in the “white dialect” which is well understood by the whole population. Words which were not agreed upon by all regions in terms of pronunciation or name were excluded from the final test material.
The test materials that were used in the developed software were voice-recorded of a native Saudi radio announcer/host. The recording speaker was asked to utter the test materials with a unified performance. Audio recording was carried out in a recording studio with minimal background noise. The recorded material was reviewed and, if necessary, revised and re-recorded to correct any pronunciation errors, background noise, or inconsistencies. Pilot testing of the recorded material was carried out with a small group of children with normal hearing, and any identified issue was edited to produce the final test material.
To develop a software application that incorporates the SPSI, a professional software development company was hired to develop an android-based software application. A 2-month trial of the software was carried out at King Abdullah Ear Specialist Center, Riyadh, Saudi Arabia. During this period, the test was assessed by both the development team and additional expert audiologists. Afterward, the first version of the software was released.
Results
The SPSI test includes words and sentences. The test contains 4-word cards and 2 sentence cards. Each card contains 5 pictures (Figure 2). During the test, the examiner selects a card, and the application presents this card twice, with the items displayed in random order. For each test, the listener is thus exposed to 10 items in total. The application operates in 3 different modes: in quiet, with background noise, and with competing sentences.
- Sample from the developed Saudi pediatric speech. A&B) The Saudi pediatric speech intelligibility application interface. C) Examples of the word. D) Sentence cards. PSI: pediatric speech intelligibility
The software platform is an android-based user-friendly application (Figure 2). The test can also be implemented on paper or on a desktop computer via a CD/DVD. The application includes an option for automatic calculation of the results, with detailed responses shown and scores displayed as percentages. In addition, the application stores these results, and they can be retrieved and analyzed at any time. Each examiner has their own user account with their own patients, through which the examiner can revise the results word by word to check the answers.
A total of 100 children were included in the pilot testing of the SPSI. They were recruited from their schools in the 5 main regions in Saudi Arabia (Central, South, North, West, and East). None of the participants demonstrated hearing impairment, and all completed the SPSI test.
When evaluating the test words, one term (cat) was changed. This was due to that fact that different words were used by the participants used to name the picture. When evaluating the test sentences, 2 showed discrepancies in how the participants reported them. These were “the boy reads a book” and “the boy rides a bicycle”. As a result, clearer pictures were used to replace the initial ones.
In addition, 3 images were changed. An image displaying 2 feet was replaced with an image displaying a single foot and the images illustrating hair and flowers were changed from cartoon representations to photographs of real objects.
Discussion
This study introduces a new speech intelligibility test compatible with the Saudi Arabic dialect. Pilot testing has demonstrated its practicality and feasibility. There are several justifications behind designing a test for the Saudi Arabic dialect instead of the universally understood MSA. Dialectic Arabic is used in everyday social interactions and is the form to which children have the highest exposure, while MSA is more prevalent in formal contexts.12,13 Additionally, while MSA is typically taught in school, the local dialect is often acquired through incidental learning, posing challenges for children with hearing impairments who may have a lower degree of exposure to informal speech. It is crucial for children with hearing impairments to acquire dialectic Arabic to support their daily communication needs.14 Despite the availability of the PSI test in other Arabic dialects such as Egyptian Arabic, the significant differences between these dialects necessitates a specific test for the Saudi Arabic dialect.
Compared to traditional clinical assessment procedures, the use of an interactive application on a tablet can be more engaging for children, potentially enhancing their participation and interest in the test. Moreover, employing technology may make the testing process enjoyable, leading to more accurate results. Additionally, this pilot study benefited from a large sample size drawn from various regions of Saudi Arabia, enhancing the generalizability of the findings.
Study limitations
The SPSI was developed for the Saudi Arabic dialect, this necessarily limits its applicability in regions in which different Arabic dialects are spoken. Furthermore, we carried out the testing in a controlled environment on children with normal hearing, and we have yet to fully explore its performance in real-world settings or with children with hearing impairments. Therefore, we plan additional studies to address these limitations.
In conclusion, the SPSI test has the potential to enhance speech evaluation practices in Saudi Arabia by offering a standardized, user-friendly tool that accounts for local dialect variations and cultural sensitivities. Its development signifies a proactive step towards ensuring comprehensive and accurate speech intelligibility assessment, particularly in children with hearing impairments. However, further research and validation studies, including comparing it to existing Arabic speech tests, are necessary to establish the reliability and validity of the SPSI test across various clinical settings and age groups.
Acknowledgment
The authors gratefully acknowledge the MEDEL - Saudi Arabia team for their indispensable assistance in this study.
Footnotes
Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company.
- Received July 7, 2024.
- Accepted September 27, 2024.
- Copyright: © Saudi Medical Journal
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