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April-June 2022 | Volume 24 | Issue 113

 Original Article

Determination of a Cutoff for Noise Sensitivity:

Psychometric Evaluation of the Turkish Noise Sensitivity
Questionnaire (Tr-NoiSeQ)
Asuman Alnıaçık, Eda Çakmak
Department of Audiology, Faculty of Health Sciences, Başkent University, Ankara, Turkey

Abstract
Context: There is a need for a clear cutoff to use noise sensitivity (NS) scale as a prediagnostic tool in research and clinical use. Aims: Noise
sensitivity questionnaire (NoiSeQ) was adapted into Turkish language (Tr-NoiSeQ); validity and reliability of the Tr-NoiSeQ were assessed.
The cutoff for the Tr-NoiSeQ was determined. Settings and design: A descriptive study within subject design. Materials and methods: A
group of 402 participants aged between 18 and 52 years filled the Tr-NoiSeQ and the Turkish version of Weinstein noise sensitivity scale (Tr-
WNSS) via internet. Statistical analysis used: Cronbach alpha (a) and the Spearman Brown coefficient were calculated for the reliability;
Pearson correlation coefficient (r) and confirmatory factor analysis (CFA) were used for the validity. The receiver-operating characteristic
(ROC) curve was used to calculate cutoff value of the Tr-NoiSeQ. Results: For the Tr-NoiSeQ, Cronbach a was 0.92, Spearman Brown
coefficient was 0.93 (P < 0.05). A high significant correlation between the Tr-WNSS and the Tr-NoiSeQ was obtained (r = 0.76, P < 0.05).
The fit indexes of the model were obtained as (x2 = 1361.06, df = 546, P < 0.001), x2 / df = 2.49, root mean square error of
approximation = 0.06, comparative fit index = 0.83, goodness of fit index = 0.82. The ROC curve showed that the cutoff for the Tr-
NoiSeQ was 53 with a 0.92 sensitivity and a 0.85 specificity (P  0.05). Conclusion: The Tr-NoiSeQ is a valid and reliable tool for use in both
clinical practice and research. The Tr-NoiSeQ seems to be consistent with the Tr-WNSS and can be used as a screening tool to evaluate NS in
audiology.

Keywords: Cutoff, hearing, noise, questionnaire, sensitivity and specificity

Key Messages: Individual noise sensitivity can be quantified
and classified by using a clear cutoff in scales. This
quantification in terms of noise sensitivity helps to obtain
more realistic and accurate results in clinical practice and
researches.
INTRODUCTION
Noise can be defined as unwanted sound which may
adversely affect the health and well-being of individuals.
However, people’s attitudes and behavior toward noise can
vary widely, indicating that people do not equally adapt to
noise. This variability is usually explained under the term
“noise sensitivity” (NS).[1,2]
The NS has been defined as a state of sensitivity to noise or
sound that emerges both as a stable personality trait covering
an attitude toward noise and as an internal state that increases
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the individual’s degree of reactivity to noise.[1-5] NS is not a
synonym of noise annoyance but a predictor of it. Because the
reaction to noise in terms of NS may include not only
annoyance but also apathy, frustration, depression, anger,
exhaustion, agitation, withdrawal, and helplessness.[1-4] It has
been reported that estimated amount of variance in annoyance
and dissatisfaction accounts for 10% to 26% of NS scores. In
addition, individuals with high NS are more affected by noise,
Address for correspondence: Asuman Alnıaçık, Faculty of Health Sciences,
Department of Audiology, Başkent University, Baglica Campus, Eskisehir
Road, 18.km Fatih Sultan Mehmet Street, Ankara, 06810, Turkey.
E-mail: asumanalniacik@gmail.com
Received: 16 June 2021 Revised: 6 August 2021
Accepted: 20 August 2021 Published: 25 July 2022
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as
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DOI: How to cite this article: Alnıaçık A, Çakmak E. Determination of a

10.4103/nah.nah_46_21 cutoff for noise sensitivity: Psychometric evaluation of the Turkish Noise
Sensitivity Questionnaire (Tr-NoiSeQ). Noise Health 2022;24:82-8.

82 © 2022 Noise & Health | Published by Wolters Kluwer - Medknow

 Alnıaçık and Çakmak: Determination of a cutoff for the Tr-NoiSeQ
and they pay more attention to noise and perceive noise as
more threatening.[2-5]
Although there is no general consensus about the prevalence
of NS, 17.1% of the participants reported NS in Widen and
Erlandsson’s study with 1285 Swedish youth aged 13 to 19
years.[6]
The NS is an important issue studied by other disciplines
related to audiology. As it can be genetic or familial, it is the
subject of research in genetic studies related to the underlying
causes.[7,8] In addition, it may also have central origin.
Kliuchko et al. examined the view that NS is associated
with altered processing in the central auditory system by
using magnetic resonance imaging in 80 participants with low
and high NS scores in terms of self-administered NS
questionnaire.[9] They reported that NS is related to
enlarged primary auditory areas in the left hemisphere,
enlarged bilateral hippocampus and temporal pole,
increased volume of the right anterior insula, and
emphasized that NS is related to the morphology of
auditory-limbic brain areas.[9,10]
In most reports attempting to explain NS in its more
psychological and social aspects, it was associated with
low scholastic skills, insecurity in social
communication,[11] neuroticism, depressive symptoms,
psychological distress, and being more sensitive to sensory
stimuli.[12] Recent studies reported that NS can be a specific
predictor of psychological health and the risk of
psychological discomfort may increase depending on NS
when exposed to road traffic noise[13] or the nonrestorative
sleep can be predicted by NS especially in low-income
families.[14] However, in mild traumatic brain injury study,
it was reported that NS may have clinical use in marking
vulnerability to persistent post concussive symptoms.[15]
From an audiological point of view, the relationship between
hearing functions and NS has not been fully understood yet.
Some reports on the relationship between NS and
physiological correlates have shown that NS is not
associated with auditory acuity in individuals with normal
hearing.[2,16,17] Stansfeld did not find a significant difference
in terms of NS in participants with normal and impaired
hearing thresholds.[2] In addition, no significant correlation
was found between NS and audiological findings such as pure
tone hearing thresholds,[16,17] loudness perception,[16] and
Distortion product otoacoustic emissions (DPOAE)
amplitudes.[17] To evaluate the sensory component of NS
in detail, Ellermeier et al. conducted a NS research with 61
participants aged between 19 and 37 years and used
psychophysical measurement parameters including the
mean absolute threshold, the threshold produced by the
poorer ear alone, the difference threshold, the individual
magnitude-estimation exponent, the slope parameter of the
loudness category-scaling function, the mean unpleasantness
rating of 10 sounds, and the slope of the function relating
reaction time to SPL.[16] The 52-item psychometric
questionnaire “Lärm Empfindlichkeits Fragebogen”[18] was
Noise & Health ¦ Volume 24 ¦ Issue 113 ¦ April-June 2022
used to assess NS. The results showed that only 15.2% of the
variance in NS scores was explained by measurement
parameters and there was a small but significant effect
between NS and loudness scaling, and ratings of the
unpleasantness of sounds. The researchers concluded that
NS measured by a psychometric questionnaire was largely
unrelated to the psychophysical variables of auditory
functions. Likewise, Heinonen-Guzejev et al. did not find
any significant differences in terms of NS between noise
sensitive and non-noise sensitive subjects.[19] On the other
hand, they reported that NS was associated with self-reported
hearing impairment, especially among younger subjects, and
higher NS scores were obtained as the self-rated hearing
disability increased.[19]
Hyperacusis is the other important audiological issue whose
relationship with NS has been investigated. NS is not a
synonym of hyperacusis defined as an abnormally strong
reaction to sounds perceived by the auditory system and
manifests itself as a physical discomfort to low, medium,
or high-intensity sounds.[20] As hyperacusis is related to the
perceived loudness of the sound, NS is more about the
processing of the noise, not the loudness of the sound.
Neurophysiological studies suggest that hyperacusis occurs
due to functional changes in the central auditory system and
in the connections between the auditory system and other
brain structures.[21] Similar to hyperacusis, recent studies
showed that NS is related to the morphology of auditory-
limbic brain areas referring that it may have a central origin.[9]
Summing up all these studies, individual variability in NS is
an important issue that has been frequently studied in
individuals with normal hearing[16] and hearing loss[22] as
(i) an individual susceptibility in genetic research,[7,8] (ii) a
vulnerability factor in tinnitus,[6] and (iii) a personality trait in
decreased sound tolerance including hyperacusis.[17]
Moreover, hidden hearing loss due to synaptopathy at the
level of afferent cochlear innervation of the auditory nerve
cannot be detected by clinical, behavioral, or physiological
measurements such as NS. However, it may cause perceptual
complaints such as a decrease in the performance of speech
understanding especially in a noisy environment.[23] Thus,
NS should also be examined as a perceptual variable in
hidden hearing loss.
To evaluate the NS in the field of audiology on an individual
basis, there is a need for an assessment tool that serves to
clearly distinguish between individual with and without NS.
As NS is also reported in individuals with normal hearing and
reflects a personality trait, the scales evaluating the NS have
been standardized as psychometric tools measuring attitudes
and behaviors. The Weinstein noise sensitivity scale
(WNSS),[1] Turkish version (Tr-WNSS),[24] and the noise
sensitivity questionnaire (NoiSeQ)[25] are two widely used
psychometric tools to assess NS. To classify the quantitative
distribution of NS scores on these scales, instead of a clear
cutoff, individuals scoring in the lower 1/3 segment[1] or less
than 25% quartile[25] have been classified as sensitive to
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 Alnıaçık and Çakmak: Determination of a cutoff for the Tr-NoiSeQ
noise, whereas individuals scoring in the upper 1/3 segment[1]
or above 75%[25] were classified as non-noise sensitive. In
such a classification, NS scores between the upper 1/3 and
lower 1/3 or between 25% and 75% may cause uncertainty in
identifying the presence of NS, consequently this uncertainty
can also lead to potential confusions in the statistical analysis.
In this regard, only Ellermeier et al., in which we previously
discussed the relationship between audiological findings and
NS, used a median score (med = 81) to distinguish between
noise sensitive and non-noise sensitive individuals.[16]
In audiology and in its related fields, a psychometric NS scale
can be used as a prediagnostic or screening tool to clearly
discriminate the presence of NS by using a clear cutoff in
terms of the complaints that the individual experiences
perceptually and expresses subjectively. Therefore, in this
study, it was aimed to determine a clear cutoff for the
prediagnosis of NS by examining the relationship between
the Tr-WNSS and the Tr-NoiSeQ. For this purpose, it was
planned to adapt the NoiSeQ into Turkish language, to
examine the validity and reliability of the Tr-NoiSeQ, and
to determine a clear cutoff for the Tr-NoiSeQ.
SUBJECTS AND METHODS
Sampling
In the present study, the minimum number of participants for
the sample was planned as 10 times the number of items
(1:10) of the Tr-NoiSeQ. Data were collected a total of 402
participants between the ages of 18 and 52 were reached.
Instruments
The noise sensitivity questionnaire
The NoiSeQ was developed by Schutte et al.[25] to measure
global NS in the form of a 4-point Likert-type scale with 35
items in five areas of daily life: leisure, work, habitation,
communication, and sleep. The reliability (relative and
absolute G-coefficient) of this questionnaire is above 0.90,
indicating that this questionnaire satisfies the precision level 1
“accurate measurement” according to ISO 10075-3. The
internal consistency of the overall scale is as 0.90.
According to the confirmatory factor analysis (CFA), all
fit indices of four subscales (habituation, work, sleep, and
communication) in the NoiSeQ indicate an acceptable match
of the model.[26] The fit indexes of the model are as CMIN/
df = 1.66, root mean square error of approximation
(RMSEA) = 0.048, comparative fit index (CFI) = 0.860,
goodness of fit index (GFI) = 0.86, adjusted goodness of
fitness index (AGFI) = 0.835.
Linguistic validation for the Turkish version of the noise
sensitivity questionnaire
In order for the NoiSeQ to be successfully adapted to Turkish
(with the courtesy of Dr Schutte), back-translation and
committee (controlled by experts in the field) methods
were combined in accordance with cultural guidelines.[27]
84
Initial translation from German to Turkish language was
carried out by two bilingual translators who worked
independently and by a German-educated expert
audiologist. These three translated versions were compared
and analyzed by the author and the other two audiologists to
check for discrepancies between content and meaning of the
original and the translated versions. After reaching a
consensus, the final translation into Turkish was back
translated German by a different bilingual independent
translator. In a pilot study with 10 interviewers randomly
selected within the university academic staff, the comprehension
of sentences and words in the final translation form was checked.
After the minor corrections, the instrument took its final form.
The Tr-NoiSeQ was completed in a form of 4-point Likert-type
scale with 35 items, from 1 (strongly agree) to 4 (strongly
disagree) statements.
The Turkish version of Weinstein NS scale
The original version of the scale was developed by Weinstein
at 1978.[1] Yildiz et al.[24] carried out the reliability and
validity study for the Tr-WNSS, which consists of 21
items, with 210 participants (105 women and 105 men)
between the ages of 18 and 55. Test retest reliability of the
Tr-WNSS with 64 participants is as 0.92. The validity of the
scale describes a two-factor structure, and the fit indexes of
the model are as CMIN/df = 1.584, RMSEA = 0.054,
CFI = 0.888, GFI = 0.892, AGFI = 0.866.
Administration of the questionnaires
The Tr-NoiSeQ and the Tr-WNSS forms were prepared as an
electronic survey. The participants filled the questionnaires
via the internet. By sharing the research link on social media
including private groups such as youth and scientific groups,
the opportunity to reach more participants was provided. It
took about 15 minutes for a single participant to fill the
questionnaires.
Statistical analysis
Statistical Package for the Social Sciences (SPSS) version
25.0 and SPSS AMOS version 25.0 (IBM Corp, Armonk,
New York, USA) was used. Normality of distribution was
evaluated by Kolmogorov Smirnov test and homogeneity of
variances by Levene test. The reliability analyses of the Tr-
NoiSeQ were examined with the Cronbach a and the
Spearman–Brown coefficient. Pearson correlation
coefficient was calculated to determine the validity
coefficient. To assess the validity of the Tr-NoiSeQ, CFA
was used. The fit indices of the model were tested with x2/df ,
RMSEA, CFI, and GFI. The receiver-operating characteristic
(ROC) curve analysis was used to calculate sensitivity,
specificity, and optimal cutoff value of the Tr-NoiSeQ. All
data were set of a = 0.05 significance level.
Ethical aspects
This study was approved by Başkent University Institutional
Review Board and Ethics Committee (Project No: KA21/
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 Alnıaçık and Çakmak: Determination of a cutoff for the Tr-NoiSeQ
178). The purpose and the terms of participation of this
research were declared to the all participants on the
electronic questionnaire form. Informed consent was
obtained from all participants by checking the }I
voluntarily agree to participate in this study} option on the
electronic questionnaire form.
RESULTS
Descriptive statistics
This study was carried out with 402 subjects (79% females,
21% males) between the ages of 18 and 52. Their mean age
was 27.21 (standard deviation [SD] = 8.86) years. The Tr-
NoiSeQ scores showed a normal distribution in terms of
gender (for female Kolmogorov–Smirnov Z = 0.047,
P = 0.089; for male Kolmogorov–Smirnov Z = 0.071,
P = 0.200) and age (the Kolmogorov–Smirnov Z = 0.045,
0.059).
Psychometric analysis
The reliability analysis of the Tr-NoiSeQ was calculated by
the internal consistency coefficient and the split half methods.
The Cronbach a coefficient and the Spearman–Brown
coefficient were found as 0.92 and 0.93, respectively (P <
0.05). In terms of subfactors in the Tr-NoiSeQ, the Cronbach
a coefficient was as 0.61 for leisure, 0.71 for habitation, 0.78
for communication, 0.77 for work, and 0.87 for sleep (P <
0.05). This indicated that the Cronbach a values of all
subfactors except leisure were obtained above limit value
of 0.70.
To validate the Tr-NoiSeQ, the concurrent validity and the
CFA were used. As given in the scatter plot presented in
Figure 1, the Pearson correlation coefficient between Tr-
WNSS and Tr-NoiSeQ was found statistically significant
(r = 0.76, P < 0.05), indicating a high correlation between
Tr-WNSS and Tr-NoiSeQ. When examined the modification
Figure 1: The scatter plot between the Turkish version of Weinstein
noise sensitivity scale (Tr-WNSS) scores and the Turkish noise
sensitivity questionnaire (Tr-NoiSeQ) scores.
Noise & Health ¦ Volume 24 ¦ Issue 113 ¦ April-June 2022
indexes of the Tr-NoiSeQ, the covariance was corrected
between the 11th and 22nd items in the leisure subfactor,
between the 4th and 33rd items in the habitation subfactor,
between the 5th and 12th and between the 19th and 20th items
in the communication subfactor. According to the CFA, the fit
indexes of the model were obtained as (x2 = 1361.06,
df = 546, P < 0.001), x2/df = 2.49, RMSEA = 0.06,
CFI = 0.83, GFI = 0.82 [Figure 2].
The cutoff for the Tr-NoiSeQ
To determine a cutoff for the Tr-NoiSeQ score in terms of NS,
ROC curve analysis was used. Based on the Tr-WNSS
scoring system, the highest 1/3 scores were identified as
high NS and the lowest 1/3 scores were identified as low
NS. After classifying the individuals participating in this
study as with or without NS according to the Tr-WNSS
scoring, a cutoff for the NS was determined depending on
the scores of the Tr-NoiSeQ. As a result of the ROC curve, the
cutoff value for the Tr-NoiSeQ was calculated as 53 with a
0.92 sensitivity and a 0.85 specificity (P  0.05). Area under
the curve (AUC) was absolutely near the value of 1
(AUC = 0.94, P < 0.05), indicating a perfect and
statistically significant value [Figure 3].
DISCUSSION
The validity and reliability study of Tr-NoiSeQ was
conducted to measure global NS as well as the NS for
different everyday situations such as leisure, work,
habitation, communication, and sleep.
When the internal consistency of the Tr-NoiSeQ was
examined, Cronbach a coefficient for the overall
questionnaire was 0.92 and the Spearman–Brown
coefficient was 0.93. For the leisure, habitation,
communication, work, and sleep subscales the Cronbach a
values were found 0.61, 0.71, 0.78, 0.77, and 0.87,
respectively (P < 0.05). These results showed that the
items of the scale were analyzed consistently in terms of
the individual’s self-assessment of NS and the Tr-NoiSeQ has
a high reliability.
The reliability results of the Tr-NoiSeQ were found to be
consistent with the reliability data of the original NoiSeQ.
Similar to this study, in the original NoiSeQ, the internal
consistency of the overall questionnaire (the Cronbach
a = 0.90) and of all subscales except leisure subscale
exceeded the lower limit (0.70).[25,26] Schutte et al.
reported that the reason why the leisure subscale does not
meet this criterion was the different preferences between
individuals in terms of leisure activities.[25] In addition,
they stated that all items in the leisure subscale probably
did not cover all possible activities, and that if the number of
items increase, the reliability of this subscale could increase
to 0.70.
According to the CFA, the Tr-NoiSeQ showed a multiple
structure with more than five factors. However, to fit the
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 Alnıaçık and Çakmak: Determination of a cutoff for the Tr-NoiSeQ
Figure 2: The confirmatory factor analysis of the Turkish noise sensitivity questionnaire with five subscales. C, communication; H, habitation;
L, leisure; S, sleep; W, work.
factor structure as in the original form, all items in the Tr-
NoiSeQ were grouped into five subscales. The first two
values (x2 = 1361.06, df = 546, P < 0.001, x2/df = 2.49,
RMSEA = 0.06) of the model fit index were within
acceptable limits and the last two values (CFI = 0.83,
GFI = 0.82, P < 0.05) were obtained close to acceptable
limits. However, there was a high correlation between the Tr-
WNSS and the Tr-NoiSeQ (r = 0.76, P < 0.05). As a result,
the Tr-NoiSeQ has been validated with its five-factor
structure.
Ellermeier et al. concluded that in old reports evaluating NS
and auditory function, the lack of using psychophysical
measure and insufficient number of participants may lead
to an underestimation of the relationship between auditory
functions and NS.[16] In addition to this conclusion, we would
86
like to emphasize that there was uncertainty in terms of
people having NS according to scale scores. As NS has
been considered as a personality trait in psychological and
sociological studies and has been examined on the basis of
attitude and behavior, there was no fixed cutoff in terms of NS
scale scores and scoring was made between upper and lower
values. However, in audiology, individuals with and without
NS should be differentiated to make a prediagnosis.
Therefore, with this study, a cutoff was determined for the
first time on a scale evaluating NS. The statistical cutoff for
the Tr-NoiSeQ scale scores was 53; individuals with NS
scored 53 and above, whereas individuals without NS scored
less than 53. As NS in audiology cannot be evaluated with an
objective test method, it can be stated that Tr-NoiSeQ can be
used as a reliable screening tool to distinguish the individuals
Noise & Health ¦ Volume 24 ¦ Issue 113 ¦ April-June 2022
 Alnıaçık and Çakmak: Determination of a cutoff for the Tr-NoiSeQ
Figure 3: The receiver-operating characteristic (ROC) curve to
determine a cut of point for noise sensitivity.
with and without NS. Consistent with the cutoff, Ellermeier
et al. used a median value and reported that participants with
high NS also had higher hearing thresholds, although it was
not statistically significant in their study.[16] However, in this
study, only 1 kHz hearing threshold was obtained with
psychoacoustic methods, and the relationship between NS
and high frequency hearing thresholds was not
investigated.[16]
In the present study, demographic factors such as age and
gender were not evaluated as the main purpose is to identify
individuals with and without NS. However, on reports
examining the relationship between the NS and
demographic factors, there has been no clear consensus in
terms of age and gender.[6,28] For example, Widen and
Erlandsson examined the prevalence of tinnitus and NS
among young people in Sweden.[6] They statistically
evaluated the NS in a group consisting of 3254
participants in the 13 to 19 age group. They reported that
216 participants (17.1% of the total group studied) had NS,
the prevalence rate of NS found higher among upper
secondary school students (19.7%) compared to younger
students (14%), and this difference was found statistically
significant (F = 4.93; df =&#9617 P < 0.01; N = 1263).
Moreover, Dzhambov and Dimitrova conducted an
adaptation study in which the Bulgarian version of the NS
short form was examined for validity and reliability.[28] In
their study, the NS scores of 115 participants with a mean age
of 45.42, SD = 15.8 years were evaluated. Interestingly, they
concluded that the scale scores were higher in younger people
(r(69) = –0.363, P = 0.002, 95% confidence interval: −0.649
to −0.077).[28] In terms of gender, contrary to older reports
showing no gender effect on NS,[29,30] newer studies indicate
that females have higher NS than males.[19] Also, Heinonen-
Noise & Health ¦ Volume 24 ¦ Issue 113 ¦ April-June 2022
Guzejev et al. reported that NS was associated with self-
reported hearing disability among women, and that the
audiometric data of elderly female subjects demonstrated
somewhat better hearing levels among noise sensitive
women. It was also emphasized that the relationship was
primarily reported among young subjects (50 years and
under). These variations in the relationship between
demographic factors and NS may be due to the fact that a
cutoff point for NS was not determined in previous studies.
CONCLUSION
It has been shown that the Tr-NoiSeQ is reliable and valid tool
to evaluate the subjective NS. However, it proved to be
somewhat problematic with respect to its leisure-based
items. To increase the reliability of this subscale, it is
necessary to increase the items. However, the Tr-NoiSeQ
seems to be consistent with the Tr-WNSS and it can be used
as a screening tool with a specific cutoff to evaluate NS both
in clinical practice and research. However, the relationship
between audiological findings and NS may have been
underestimated in reports that do not use a specific cutoff
for scoring and have insufficient number of participants.
Further research is needed to identify individuals with or
without NS according to a specific cutoff, to reveal the
audiological profiles of these individuals, and to interpret
them in terms of demographic factors such as age and gender.
Acknowledgment
The authors express their deepest appreciation to all those
who participated in this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Noise & Health ¦ Volume 24 ¦ Issue 113 ¦ April-June 2022