Gabrielle H. Saunders

Acclimatization to hearing aids.

Objective: To investigate acclimatization to hearing aids. Design: Forty‐eight subjects took part in a study in which hearing aid benefit was measured four times over the initial 3 mo of participation. At the start, 24 subjects were experienced hearing aid users and 24 had never worn a hearing aid before. Subjects wore one of three models of hearing aid with one of six different configurations (combination of frequency response and method of output limiting). Hearing aid benefit was measured with CID W‐1 spondees and the Hearing in Noise Test (HINT) test. Testing took place on Days 0 (day of fitting), 30, 60, and 90. Analyses of variance were used to determine whether hearing aid benefit changed over time as a function of hearing aid user status, hearing aid configuration, and hearing aid volume setting. Results: There were small, nonsignificant changes in hearing aid benefit over the test sessions with both sets of test materials. There were no interactions between hearing aid benefit over time and hearing aid user status or hearing aid volume setting. There was an interaction between benefit over time and hearing aid configuration on one test measure only. Conclusions: The data showed little evidence of acclimatization over the 3 mo of hearing aid use. The test materials used here were low‐ to mid‐frequency sensitive, and, therefore, it is concluded that if acclimatization did occur, it did so primarily at high frequencies. Because the HINT test has good face validity to everyday listening situations, it is suggested that the clinical ramifications of acclimatization are probably small.

Measuring hearing aid outcomes--not as easy as it seems.

Outcomes measurement in audiology has received much attention because of the need to demonstrate efficacy of treatment, provide evidence for third-party payment, carry out cost-benefit analyses, and justify resource allocation. Outcomes measurement shows the benefits obtained from a hearing aid and determines the costs of obtaining those benefits. In this article, we discuss why the seemingly simple issue of outcomes measurement is highly complex and the use of generic and disease-specific tools and the relationship between them; we also provide information regarding the International Classification of Functioning (ICF) system for selecting outcome measures. We then discuss factors complicating outcomes measurement, including discrepancies between clinically derived outcomes and functional outcomes, the ways clinicians can affect outcomes, and factors intrinsic to the patient that influence outcomes. We conclude that if the vision of moving quickly and efficiently from bench to chairside is to be realized, then clinicians must routinely measure hearing aid outcomes and researchers investigate their validity and usefulness.

Refinement and psychometric evaluation of the Attitudes Toward Loss of Hearing Questionnaire

Objective: To refine and statistically validate the Attitudes Toward Loss of Hearing Questionnaire (ALHQ) so that it will be appropriate for clinical application and to understand some of the personality attributes underlying attitudes toward hearing loss. Design: An American‐English version of an ALHQ, originally designed byBrooks (1989), was completed by 226 men; a subset of 80 also completed personality questionnaires. All subjects underwent pure‐tone testing and speech audiometry. Factor analysis was used to extract scales from the ALHQ. Reliability analyses using Cronbachs α were carried out on each scale. Test‐retest reliability was evaluated from questionnaires completed 6 to 18 mo after initial administration. Multiple regression analysis was used to examine the audiometric and personality determinants of attitudes. Results: Five reliable scales were extracted from a 24‐question version of the ALHQ: 1) Social and Emotional Impact of Hearing Loss, 2) Acceptance/Adjustment to Hearing Loss, 3) Perceived Support from Significant Others, 4) Hearing Aid Stigma, and 5) Awareness of Hearing Loss. Audiometric data explained little of the variance in attitude scores; age and other demographic factors did not correlate with attitudes either. The personality traits of extroversion, self‐esteem, and anxiety/neuroticism played a larger role in determining attitude. Conclusions: The ALHQ is psychometrically acceptable and is a potentially useful clinical tool. It is quick and easy to complete and to score and could be used as a basis for counseling and for following attitude change in patients over time.

Hearing loss in veterans and the need for hearing loss prevention programs

Currently, there are more than 445,000 veterans receiving compensation for hearing loss associated with military service, and 395,000 receiving compensation for service-related tinnitus. In addition to compensation payments, service-related hearing disorders cost the US Department of Veterans Affairs in terms of provision of hearing aids, hearing aid-related services, and clinical services at its 220 facilities nationwide. It is imperative that hearing conservation among military personnel and veterans be addressed. In this paper, we describe the rationale for and the development of a multimedia Hearing Loss Prevention Program aimed at preventing the progression of hearing loss among veterans associated with social, recreational, and nonmilitary occupational noise exposure. The program was developed based on the principles outlined in the Health Belief Model of Rosenstock (1966) and the Health Promotion Model of Pender et al. (2002).

Speech intelligibility enhancement using hearing-aid array processing

Microphone arrays can improve speech recognition in the noise for hearing-impaired listeners by suppressing interference coming from other than desired signal direction. In a previous paper [J. M. Kates and M. R. Weiss, J. Acoust. Soc. Am. 99, 3138-3148 (1996)], several array-processing techniques were evaluated in two rooms using the AI-weighted array gain as the performance metric. The array consisted of five omnidirectional microphones having uniform 2.5-cm spacing, oriented in the endfire direction. In this paper, the speech intelligibility for two of the array processing techniques, delay-and-sum beamforming and superdirective processing, is evaluated for a group of hearing-impaired subjects. Speech intelligibility was measured using the speech reception threshold (SRT) for spondees and speech intelligibility rating (SIR) for sentence materials. The array performance is compared with that for a single omnidirectional microphone and a single directional microphone having a cardioid response pattern. The SRT and SIR results show that the superdirective array processing was the most effective, followed by the cardioid microphone, the array using delay-and-sum beamforming, and the single omnidirectional microphone. The relative processing ratings do not appear to be strongly affected by the size of the room, and the SRT values determined using isolated spondees are similar to the SIR values produced from continuous discourse.

Application of the health belief model: Development of the hearing beliefs questionnaire (HBQ) and its associations with hearing health behaviors

Abstract Objective: To develop a hearing beliefs questionnaire (HBQ) that assesses hearing beliefs within the constructs of the health belief model, and to investigate whether HBQ scores are associated with hearing health behaviors. Design: A 60-item version of the questionnaire was developed and completed by 223 participants who also provided information about their hearing health behaviors (help seeking, hearing-aid acquisition, and hearing-aid use). Study sample: Individuals aged between 22 and 90 years recruited from a primary care waiting area at a Veterans hospital. Seventy-six percent were male, 80% were Veterans. Results: A 26-item version of the HBQ with six scales was derived using factor analysis and reliability analyses. The scales measured: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, and cues to action. HBQ scores differed significantly between individuals with different hearing health behaviors. Logistic regression analyses resulted in robust models of hearing health behaviors that correctly classified between 59% and 100% of participant hearing health behaviors. Conclusions: The HBM appears to be an appropriate framework for examining hearing health behaviors, and the HBQ is a valuable tool for assessing hearing health beliefs and predicting hearing health behaviors.

The Performance-Perceptual Test (PPT) and Its Relationship to Aided Reported Handicap and Hearing Aid Satisfaction

Objective: Results of objective clinical tests (e.g., measures of speech understanding in noise) often conflict with subjective reports of hearing aid benefit and satisfaction. The Performance-Perceptual Test (PPT) is an outcome measure in which objective and subjective evaluations are made by using the same test materials, testing format, and unit of measurement (signal-to-noise ratio, S/N), permitting a direct comparison between measured and perceived ability to hear. Two variables are measured: a Performance Speech Reception Threshold in Noise (SRTN) for 50% correct performance and a Perceptual SRTN, which is the S/N at which listeners perceive that they can understand the speech material. A third variable is computed: the Performance-Perceptual Discrepancy (PPDIS); it is the difference between the Performance and Perceptual SRTNs and measures the extent to which listeners “misjudge” their hearing ability. Saunders et al. in 2004 examined the relation between PPT scores and unaided hearing handicap. In this publication, the relations between the PPT, residual aided handicap, and hearing aid satisfaction are described. Design: Ninety-four individuals between the ages of 47 and 86 yr participated. All had symmetrical sensorineural hearing loss and had worn binaural hearing aids for at least 6 wk before participating. All subjects underwent routine audiological examination and completed the PPT, the Hearing Handicap Inventory for the Elderly/Adults (HHIE/A), and the Satisfaction for Amplification in Daily Life questionnaire. Sixty-five subjects attended one research visit for participation in this study, and 29 attended a second visit to complete the PPT a second time. Results: Performance and Perceptual SRTN and PPDIS scores were normally distributed and showed excellent test-retest reliability. Aided SRTNs were significantly better than unaided SRTNs; aided and unaided PPDIS values did not differ. Stepwise multiple linear regression showed that the PPDIS, the Performance SRTN, and age were significant predictors of scores on the HHIE/A such that greater reported handicap is associated with underestimating hearing ability, poorer aided ability to understand speech in noise, and being younger. Scores on the Satisfaction with Amplification in Daily Life were not well explained by the PPT, age, or audiometric thresholds. When individuals were grouped by their HHIE/A scores, it was seen that individuals who report more handicap than expected based on their audiometric thresholds, have a more negative PPDIS, i.e., underestimate their hearing ability, relative to individuals who report expected handicap, who in turn have a more negative PPDIS than individuals who report less handicap than expected. No such patterns were apparent for the Performance SRTN. Conclusions: The study showed the PPT to be a reliable outcome measure that can provide more information than a performance measure and/or a questionnaire measure alone, in that the PPDIS can provide the clinician with an explanation for discrepant objective and subjective reports of hearing difficulties. The finding that self-reported handicap is affected independently by both actual ability to hear and the (mis)perception of ability to hear underscores the difficulty clinicians encounter when trying to interpret outcomes questionnaires. We suggest that this variable should be measured and taken into account when interpreting questionnaires and counseling patients.

Impact on hearing aid targets of measuring thresholds in dB HL versus dB SPL.

Audiometric measurements are traditionally made in dB HL, which by definition are specified relative to the sound pressure level (SPL) in a coupler. Real-ear dB SPL is then estimated by applying an average ear transform to the coupler value. However, individual variation in ear canal acoustics and variations in transducer placement strongly influence the dB SPL of signals arriving at the eardrum. In this paper, data from 1814 ears are presented, showing that the distribution of eardrum dB SPL for a fixed signal level varies across ears and across frequency by as much as 40 dB. The impact of this variance upon hearing aid targets computed with the NAL-NL1 fitting algorithm is examined by comparing the targets obtained from using an average transform with those obtained when audiometric data in dB SPL are obtained by applying individually measured real-ear-to-coupler difference (RECD) values to dB HL thresholds. The impact can be considerable. Sumario Tradicionalmente, las mediciones audiométricas se realizan en dB HL, que por definitión se especifican en relación con el nivel de presíón sonora (SPL) en un acoplador. Los dB SPL de oído-real se estiman, aplicando una transformatión promedio al oído, en relación con el valor del acoplador. Sin embargo, las variaciones individuales en la acústica del conducto auditivo y las variaciones en la colocación del transductor influyen fuertemente en las señales en dB SPL, que llegan a la membrana timpánica. En este artículo, se presenta la información de 1814 oídos, mostrando que la distribución de los dB SPL en el tímpano, para un nível fijo de señal, varía en los diferentes oídos y en las diferentes frecuencias hasta en 40 dB. Se examinó el impacto de esta variación sobre las metas en los auxiliares auditivos, estimadas con el algoritmo de adaptatión NAL-NL 1. Este análisis se realizó comparando los valores meta logrados utilizando una transformación promedio, con aquellos datos audiométricos en dB SPL, obtenidos aplicando individualmente las mediciones de la diferencia oído real/acoplador (RECD) a los umbrales en dB HL. El impacto puede ser considerable.

The performance-perceptual test and its relationship to unaided reported handicap.

Objective Measurement of hearing aid outcomes is necessary for demonstration of treatment efficacy, third-party payment, and cost-benefit analysis. Outcomes are usually measured with hearing-related questionnaires and/or tests of speech recognition. However, results from these two types of test often conflict. In this paper, we provide data from a new test measure, known as the Performance-Perceptual Test (PPT), in which subjective and performance aspects of hearing in noise are measured using the same test materials and procedures. A Performance Speech Reception Threshold (SRTN) and a Perceptual SRTN are measured using the Hearing In Noise Test materials and adaptive procedure. A third variable, the discrepancy between these two SRTNs, is also computed. It measures the accuracy with which subjects assess their own hearing ability and is referred to as the Performance-Perceptual Discrepancy (PPDIS). Design One hundred seven subjects between 24 and 83 yr of age took part. Thirty-three subjects had normal hearing, while the remaining seventy-four had symmetrical sensorineural hearing loss. Of the subjects with impaired hearing, 24 wore hearing aids and 50 did not. All subjects underwent routine audiological examination and completed the PPT and the Hearing Handicap Inventory for the Elderly/Adults on two occasions, between 1 and 2 wk apart. The PPT was conducted for unaided listening with the masker level set to 50, 65, and 80 dB SPL. Results PPT data show that the subjects with normal hearing have significantly better Performance and Perceptual SRTNs at each test level than the subjects with impaired hearing but that PPDIS values do not differ between the groups. Test-retest reliability for the PPT is excellent (r-values > 0.93 for all conditions). Stepwise multiple regression analysis showed that the Performance SRTN, the PPDIS, and age explain 40% of the variance in reported handicap (Hearing Handicap Inventory for the Elderly/Adults scores). More specifically, poorer performance, underestimation of hearing ability and younger age result in greater reported handicap, and vice versa. Conclusion Reported handicap consists of a performance component and a (mis)perception component, as measured by the Performance SRTN and the PPDIS respectively. The PPT should thus prove to be a valuable tool for better understanding why some individuals complain of hearing difficulties but have only a mild hearing loss or conversely report few difficulties in the presence of substantial impairment. The measure would thus seem to provide both an explanation and a counseling tool for patients for whom there is a mismatch between reported and measured hearing difficulties.

Description of Adults Seeking Hearing Help for the First Time According to Two Health Behavior Change Approaches: Transtheoretical Model (stages of Change) and Health Belief Model

Objectives: Several models of health behavior change are commonly used in health psychology. This study applied the constructs delineated by two models—the transtheoretical model (in which readiness for health behavior change can be described with the stages of precontemplation, contemplation and action) and the health belief model (in which susceptibility, severity, benefits, barriers, self-efficacy, and cues to action are thought to determine likelihood of health behavior change)—to adults seeking hearing help for the first time. Design: One hundred eighty-two participants (mean age: 69.5 years) were recruited following an initial hearing assessment by an audiologist. Participants’ mean four-frequency pure-tone average was 35.4 dB HL, with 25.8% having no hearing impairment, 50.5% having a slight impairment, and 23.1% having a moderate or severe impairment using the World Health Organization definition of hearing loss. Participants’ hearing-related attitudes and beliefs toward hearing health behaviors were examined using the University of Rhode Island Change Assessment (URICA) and the health beliefs questionnaire (HBQ), which assess the constructs of the transtheoretical model and the health belief model, respectively. Participants also provided demographic information, and completed the hearing handicap inventory (HHI) to assess participation restrictions, and the psychosocial impact of hearing loss (PIHL) to assess the extent to which hearing impacts competence, self-esteem, and adaptability. Results: Degree of hearing impairment was associated with participation restrictions, perceived competence, self-esteem and adaptability, and attitudes and beliefs measured by the URICA and the HBQ. As degree of impairment increased, participation restrictions measured by the HHI, and impacts of hearing loss, as measured by the PIHL, increased. The majority of first-time help seekers in this study were in the action stage of change. Furthermore, relative to individuals with less hearing impairment, individuals with more hearing impairment were at more advanced stages of change as measured by the URICA (i.e., higher contemplation and action scores relative to their precontemplation score), and they perceived fewer barriers and more susceptibility, severity, benefits and cues to action as measured by the HBQ. Multiple regression analyses showed participation restrictions (HHI scores) to be a highly significant predictor of stages of change explaining 30% to 37% of the variance, as were duration of hearing difficulty, and perceived benefits, severity, self-efficacy and cues to action assessed by the HBQ. Conclusions: The main predictors of stages of change in first-time help seekers were reported participation restrictions and duration of hearing difficulty, with constructs from the health belief model also explaining some of the variance in stages of change scores. The transtheoretical model and the health belief model are valuable for understanding hearing health behaviors and can be applied when developing interventions to promote help seeking.