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Introduction
Adolescence is a time of rapid changes in cognitive, physical, social, and emotional development. Adolescents must acclimate to developing environmental pressures and adapt to growing needs and skills [1]. These rapid changes can lead to the emergence of various stressors that affect the well-being of adolescents [2]. The deaf and hard-of-hearing (DHH) child or adolescent in a family may affect all family members [3]. Deafness puts a person in a difficult place [4], while relationships with family members and DHH peers provide endless opportunities to learn how to resolve interpersonal, emotional, and social problems [5]. 
Although DHH students can use sign or spoken language, hearing loss affects their learning capacity [6]. Moreover, adolescence is a critical period of development characterized by significant physical, cognitive, emotional, and social growth [7]. Changes in this period, in addition to challenging school requirements, increasing peer interactions, and evolving communication patterns with friends and family members, may expose adolescents to undesirable experiences and challenge their abilities [8]. The relationship between quality of life (QoL) and psychological stress has been the focus of much research. Anxiety, depression, and stress are very common and often associated with general health problems that often occur in adolescence [9].
Cognitive vulnerability-stress theory on the development of depression hypothesizes that when adolescents experience negative life events, negative patterns of thinking play a critical role in depressive symptoms [10]. Stress is one of the factors that negatively affect an individual’s well-being and QoL [11]. When an adolescent cannot cope with stressful life events, the symptoms of depression may increase [12]. In addition, there is a wide range of anxiety disorders. For this reason, various theoretical models try to explain the causes of these problems. However, models of anxiety disorders suggest that perceived threats and stressful events lead to symptoms of anxiety through overly cognitive distortions and frightening biases [13]. Anxiety and stress also explain a large percentage of depressive symptoms in adolescents [9]. Some evidence suggests that increased stressors are a potential threat to adolescents’ well-being and QoL [11].
Well-being is associated with positive career, health, and social outcomes in life [14]. QoL is closely related to public health [15]. Many factors affect and contribute to a person’s QoL which refers to a person’s perceived mental and physical well-being [16]. QoL includes well-being, health, satisfaction with daily living, and social participation [17]. Health-related QoL can be affected by disease and treatment and is related to factors that affect people’s QoL [16]. Sensory impairments such as hearing loss can affect the QoL [17]. Numerous studies have revealed that DHH people have poorer social and physical functioning, QoL, and mental health [18-20]. The QoL and well-being of these people need to be addressed. However, few studies have predicted psychological well-being based on psychosocial factors in DHH adolescents.
Wiseman et al. revealed that the temperament of DHH students significantly predicted stress in parents [21]. A study by Adibsereshki et al. showed that well-being and happiness were closely related to coping strategies in deaf adolescents [22]. Adigun stated that self-efficacy and self-esteem had a direct and positive relationship with intimate image diffusion among deaf adolescents [23]. Brice and Strauss concluded that QoL is associated with self-concept, identity development, and adjustment in deaf adolescents [1]. Kushalnagar et al. suggested that the QoL positively correlated with parent relations, but negatively related to perceived stigma and depression symptoms in DHH adolescents [24]. The findings of Fellinger et al. indicated that the general health and QoL associated with a type of hearing loss in DHH people [25]. Chia et al. suggested that psychosocial effects are associated with hearing loss. These effects include poorer mood and physical functioning, decreased well-being, social isolation, and depression [26].
DHH adolescents are faced with problems in managing emotion and behavior, where access to communication and information is incomplete at best [1]. Although there is an interest in studying the QoL in DHH adolescents [27], these adolescents face more problems than hearing peers [28]. Previous research on psychological well-being and QoL emphasizes the relationship between stress, anxiety, and depression. However, the high degree of coexistence between these problems has led experts to predict psychological well-being based on QoL, health, stress, anxiety, and depression.
DHH adolescents are more at risk for health problems, stress, anxiety, and depression than hearing adolescents. On the other hand, there was some research available on the role of health, QoL, depression, anxiety, and stress on psychological well-being in these adolescents. In addition, there is some research on the relationship between QoL, health, depression, anxiety, stress, and psychological well-being among DHH adolescents. Therefore, this study aimed to predict psychological well-being based on psychosocial factors in DHH adolescents.

Materials and Methods 
One hundred and twenty DHH adolescents who were in sixth and twelfth grades were selected by convenient sampling from secondary schools for the deaf in Isfahan City, Iran. Originally, 62 people were in the age range of 11 to 14 years and 58 people were in the age range of 15 to 19 years. Based on the academic records, participants ranged in IQ from 91 to 103 with a Mean±SD of 96.01±0.34. The inclusion criteria included sensorineural DHH>36 decibels (dB). These participants had hearing aids before the age of five. Additional criteria included an age range between 11 and 19 years with a Mean±SD of 15.92±0.38 (male 45%; female 55%), living with parents, speaking Persian as a first language, studying in deaf schools from seventh to twelfth grade, having no disorders such as cerebral palsy or autism, and being able to complete questionnaires. The exclusion criteria for subjects were neurological and psychological disorders.
The health-related QoL questionnaire (KIDSCREEN-27) was used for assessing the health-related QoL (HRQOL) of the participants. This questionnaire was designed by Robitail et al. [29] and includes 27 items assessing five subscales of HRQOL, which are physical well-being (5 items), psychological well-being (7 items), school environment (4 items), peers and social support (4 items), and parent relations and autonomy (7 items). The KIDSCREEN-27 is scored from “1” to “5”, meaning never and always, respectively. The score of the subscales is linearly converted from 0 to 100, and 100 indicates the best QoL. The reliability of the psychological well-being, physical well-being, school environment, social support and peers, and parent relations and autonomy subscales assessed through the Cronbach’s α was between 0.78 and 0.84. Its correlation with KIDSCREEN-52 has been reported in the range of 0.63 to 0.96 [29]. In Iran, Nik-Azin et al. reported the reliability for the subscales of the KIDSCREEN-27 through the Cronbach’s α between 0.64 and 0.84, and its validity from 0.42 to 0.73. The test re-test correlations ranged from 0.52 to 0.78 [30]. 
The youth QoL instrument-deaf and hard of hearing (YQOL-DHH) was used for evaluating the QoL of the participants. The YQOL-DHH was designed by Patrick et al. for DHH adolescents. It includes 32 questions evaluating three subscales of QoL, which are self-advocacy/acceptance (14 questions), participation (10 questions), and perceived stigma (8 questions). Each question is graded from “0” to “10”, and respectively means not at all to very much. Given that each of the subscales of self-advocacy/acceptance, participation, and perceived stigma have 14, 10, and 8 questions, the minimum and maximum scores for each subscale are 14 to 140, 10 to 100, and 8 to 80, respectively [31]. This questionnaire does not have a total score. In addition, a higher score on the self-advocacy/acceptance and participation subscales, and a lower score on the perceived stigma subscale indicate a higher QoL [32]. The reliability of the self-advocacy/acceptance, participation, and perceived stigma subscales estimated by test re-test coefficients, was 0.70, 0.92, and 0.78, respectively. The Cronbach’s α reliability for subscales were 0.84, 0.86, and 0.85, respectively. The validity of the subscales was between 0.28 and 0.70 [31]. In the current study, the content validity index for subscales was 0.79, 0.85, and 0.88, respectively. The reliability of the self-advocacy/acceptance, participation, and perceived stigma subscales estimated by Cronbach’s α was 0.84, 0.83, and 0.81, respectively. The reliability of the subscales using the test re-test coefficients also was 0.76, 0.74, and 0.73, respectively.
The depression, anxiety, and stress scale-21 (DASS-21) were used for assessing the depression, anxiety, and stress of the participants. This questionnaire was developed by Lovibond and Lovibond and includes 21 items assessing three subscales, which are depression, anxiety, and stress. Each subscale has seven items. The DASS-21 is rated from “0” (not at all) to “3” (too high) [33]. The final score of each subscale is obtained through the sum of the scores of the related items. Scores on the DASS-21 will need to be multiplied by 2 to calculate the final score. Therefore, the minimum and maximum scores for each subscale are between 0 and 42. Higher scores are associated with higher stress, anxiety, and depression [34]. The reliability of the stress, anxiety, and depression subscales estimated by the Cronbach’s α was 0.95, 0.92, and 0.97, respectively. Also, a correlation of 0.48 was found between stress and depression, 0.53 between stress and anxiety, and 0.28 between depression and anxiety [35]. In Iran, Samani and Jokar estimated the validity coefficients for DASS-21 at 0.90. The reliability coefficients by test re-test for stress, anxiety, and depression were 0.77, 0.76, and 80, respectively [36]. 
The participants became aware of the aim of this study, using sign language or total communication. We divided the subjects into small groups and then told them how to fill out the questionnaires. Thus, DHH adolescents filled out the KIDSCREEN-27, YQOL-DHH, and DASS-21 in their classrooms. Completion of these questionnaires took about 20 to 25 minutes. Data obtained by the KIDSCREEN-27, YQOL-DHH, and DASS-21 were analyzed by stepwise regression and Pearson correlation methods. Correlation was run to explore the relationships among data. Then, the stepwise regression was performed to predict psychological well-being based on QoL, health, stress, anxiety, and depression in DHH adolescents. 

Results
The descriptive statistics for the subscales of KIDSCREEN-27 (psychological well-being, physical well-being, school environment, social support and peers, and autonomy and parent relations), YQOL-DHH (self-advocacy/acceptance, perceived stigma, and participation), and DASS-21 (depression, anxiety, and stress) are reported in Table 1.



The descriptive indicators of variables are reported in Table 1. The Kolmogorov–Smirnov test approved the normality of the distribution of scores (P>0.05). The correlations between self-advocacy/acceptance, participation, perceived stigma, stress, anxiety, depression, social support and peers, physical well-being, school environment, parent relations and autonomy, and psychological well-being are demonstrated in Table 2.



According to Table 2, psychological well-being positively correlated with self-advocacy/acceptance (r=0.70, P<0.01), participation (r=0.74, P<0.01), parent relations (r=0.17, P<0.05), and social support (r=0.31, P<0.01), but negatively correlated with perceived stigma (r=-0.67, P<0.01) and depression (r=-0.51, P<0.01). Psychological well-being had no significant association with anxiety, stress, physical well-being, and school environment stigma (P<0.01). 
To predict DHH adolescents’ psychological well-being, a stepwise regression was run. Independent error hypothesis was tested by ensuring that the Durbin-Watson was >1 and <3 [37]. Because its value was equal to 1.81, it was approved. The hypothesis of multicollinearity was tested by confirming that no predictor correlated >±0.8, a tolerance statistic >0.1, and a variance inflation factor statistic (VIF) <10 [38]. Because the tolerance statistic was close to 1 and the VIF was <2, stepwise regression analysis was used, the results of which are reported in Table 3.



As reported in Table 3, in the first phase, participation had the largest share in predicting psychological well-being. It could be explained by 54% of the variation in psychological well-being (β=1.37, t=8.22, P<0.001). In the second phase, after participation, self-advocacy/acceptance was entered into the analysis and these two variables explained 79% of the variation in psychological well-being (β=0.97, t=7.07, P<0.001). In the third phase, besides participation and self-advocacy/acceptance, perceived stigma entered into the analysis and these variables predicted 83% of the variation in psychological well-being (β=-0.84, t=5.80, P<0.001). In the last two phases, depression and social support entered the analysis and predicted 86 and 88% of the variation in psychological well-being, respectively (β=0.75, t=4.53, P<0.001; β=0.69, t=2.95, P<0.002). In the sixth phase, parent relations entered the regression and these variables predicted 89% of the change in psychological well-being (β=0.66, t=2.34, P<0.005).

Discussion
The current research predicted psychological well-being based on psychosocial factors in DHH adolescents. The results suggested that self-advocacy/acceptance, participation, social support, and parent relations had a significant and positive relationship with psychological well-being. Also, perceived stigma and depression had a significant and negative relationship with psychological well-being. In the predictive model, participation, perceived stigma, self-advocacy/acceptance, depression, social support, and parent relations explained the psychological well-being of the participants. Participation also had the most important and the greatest role.
The results were similar to Wiseman et al. who reported the temperament of DHH students significantly predicted stress in parents [21]. The result was consistent with Adigun, who revealed that self-efficacy and self-esteem had a direct and positive relationship with intimate image diffusion among DHH adolescents [23]. The findings were similar to Adibsereshki et al. who indicated that well-being and happiness were closely related to coping strategies in DHH adolescents [22]. Brice and Strauss found that QoL is associated with self-concept, identity development, and adjustment in DHH adolescents [1]. Fellinger et al. revealed the QoL and mental health was consistent with a type of hearing loss in DHH students [25]. Furthermore, the result associated with Chia et al. suggesting that well-being was closely related to QoL, physical functioning, social isolation, and depression [26].
To explain this finding, it can be said that DHH people are more vulnerable to psychological well-being than their hearing people in terms of psychological problems and mental health [28]. There is a positive relationship between self-acceptance and psychological well-being in DHH students [39]. Therefore, better self-advocacy/acceptance is associated with higher psychological well-being.
One of the important effects of hearing loss is on a person’s capability to communicate with peers and parents. Exclusion from communication can have a primary effect on daily life, causing loneliness, isolation, and feelings of frustration, especially among DHH adolescents [40]. The QoL among DHH adolescents is related to their communication with their parents [41]. The QoL positively correlated with the parent relations, but negatively related to perceived stigma and depression symptoms in DHH adolescents [24]. Previous studies suggested the importance of communication between DHH adolescents and their parents [4, 24, 42]. In other words, the QoL of DHH adolescents varies with the degree to which they relate to their parents. As the level of relationships with parents increases, the QoL also increases significantly [43]. Hearing loss can affect adolescents’ ability to develop communication and social skills. The sooner DHH adolescents begin receiving services, the more likely they are to reach their total capacity.
Although the findings of the current study explain more precisely the well-being of DHH students, there are some limitations. First, as seen in studies of DHH people, the participants were heterogeneous in their use of different educational methods, communication approaches, cause of hearing loss, and duration of use of hearing aids. These variables may affect the well-being of subjects. Additionally, only DHH adolescents whose reading skills allowed them to complete the questionnaires participated in this study.
The critical strength of this research was the participation of DHH adolescents aged 11–19 years. These results have clinical and educational implications for those psychologists working with DHH adolescents regarding the importance of QoL, health, depression, anxiety, stress, and psychological well-being during the challenging stage of adolescence. Other psychologists could choose a larger sample size. It is recommended to study the psychological well-being of DHH adolescents in clinical and educational environments based on gender and age; It is also suggested to examine the relationship between social skills and self-esteem with the psychological well-being of DHH people.
Technology-based interventions have been applied in Iran to improve mental health and QoL among some population groups. Similar technology-based interventions need to be assessed and applied to DHH adolescents in Iran. Randomized controlled trials need to be designed to evaluate how technology-based interventions can reduce stress and depression among DHH adolescents.

Conclusion
Psychological well-being is considered a combination of positive emotional states and optimal performance in individual and social life. Psychological well-being positively correlated with the QoL, but negatively correlated with psychological distress in DHH adolescents. DHH adolescents may also struggle with various psychological distress. Indeed, the QoL, health, depression, anxiety, and stress in these adolescents can affect their psychological well-being. 
This study predicted psychological well-being based on psychosocial factors in DHH adolescents. The findings showed that the QoL, health, depression, anxiety, and stress were significant predictors of the psychological well-being of DHH adolescents. Then, these variables play an important contribution to the well-being of deaf individuals. The results of this study will further help researchers and psychologists reinforce psychotherapy interventions to enhance the components of psychological well-being, QoL, and psychological distress in DHH adolescents.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Human Ethics Research Committee of the University of Isfahan. Informed consent was obtained and the participants were informed that participating in the study was optional.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization and supervision: Mohammad Ashori; Performing the experiment: Bahar Rashidi; Data analysis and writhing the manuscript: Mohammad Ashori and Bahar Rashidi. 

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors thank all deaf adolescents who participated in this study.





References