Helen Henshaw

Efficacy of Individual Computer-Based Auditory Training for People with Hearing Loss: A Systematic Review of the Evidence

Background Auditory training involves active listening to auditory stimuli and aims to improve performance in auditory tasks. As such, auditory training is a potential intervention for the management of people with hearing loss. Objective This systematic review (PROSPERO 2011: CRD42011001406) evaluated the published evidence-base for the efficacy of individual computer-based auditory training to improve speech intelligibility, cognition and communication abilities in adults with hearing loss, with or without hearing aids or cochlear implants. Methods A systematic search of eight databases and key journals identified 229 articles published since 1996, 13 of which met the inclusion criteria. Data were independently extracted and reviewed by the two authors. Study quality was assessed using ten pre-defined scientific and intervention-specific measures. Results Auditory training resulted in improved performance for trained tasks in 9/10 articles that reported on-task outcomes. Although significant generalisation of learning was shown to untrained measures of speech intelligibility (11/13 articles), cognition (1/1 articles) and self-reported hearing abilities (1/2 articles), improvements were small and not robust. Where reported, compliance with computer-based auditory training was high, and retention of learning was shown at post-training follow-ups. Published evidence was of very-low to moderate study quality. Conclusions Our findings demonstrate that published evidence for the efficacy of individual computer-based auditory training for adults with hearing loss is not robust and therefore cannot be reliably used to guide intervention at this time. We identify a need for high-quality evidence to further examine the efficacy of computer-based auditory training for people with hearing loss.

Benefits of phoneme discrimination training in a randomized controlled trial of 50- to 74-year-olds with mild hearing loss.

Objectives: The aims of this study were to (i) evaluate the efficacy of phoneme discrimination training for hearing and cognitive abilities of adults aged 50 to 74 years with mild sensorineural hearing loss who were not users of hearing aids, and to (ii) determine participant compliance with a self-administered, computer-delivered, home- and game-based auditory training program. Design: This study was a randomized controlled trial with repeated measures and crossover design. Participants were trained and tested over an 8- to 12-week period. One group (Immediate Training) trained during weeks 1 and 4. A second waitlist group (Delayed Training) did no training during weeks 1 and 4, but then trained during weeks 5 and 8. On-task (phoneme discrimination) and transferable outcome measures (speech perception, cognition, self-report of hearing disability) for both groups were obtained during weeks 0, 4, and 8, and for the Delayed Training group only at week 12. Results: Robust phoneme discrimination learning was found for both groups, with the largest improvements in threshold shown for those with the poorest initial thresholds. Between weeks 1 and 4, the Immediate Training group showed moderate, significant improvements on self-report of hearing disability, divided attention, and working memory, specifically for conditions or situations that were more complex and therefore more challenging. Training did not result in consistent improvements in speech perception in noise. There was no evidence of any test-retest effects between weeks 1 and 4 for the Delayed Training group. Retention of benefit at 4 weeks post-training was shown for phoneme discrimination, divided attention, working memory, and self-report of hearing disability. Improved divided attention and reduced self-reported hearing difficulties were highly correlated. Conclusions: It was observed that phoneme discrimination training benefits some but not all people with mild hearing loss. Evidence presented here, together with that of other studies that used different training stimuli, suggests that auditory training may facilitate cognitive skills that index executive function and the self-perception of hearing difficulty in challenging situations. The development of cognitive skills may be more important than the development of sensory skills for improving communication and speech perception in everyday life. However, improvements were modest. Outcome measures need to be appropriately challenging to be sensitive to the effects of the relatively small amount of training performed.

Computer skills and internet use in adults aged 50-74 years: influence of hearing difficulties

Background The use of personal computers (PCs) and the Internet to provide health care information and interventions has increased substantially over the past decade. Yet the effectiveness of such an approach is highly dependent upon whether the target population has both access and the skill set required to use this technology. This is particularly relevant in the delivery of hearing health care because most people with hearing loss are over 50 years (average age for initial hearing aid fitting is 74 years). Although PC skill and Internet use by demographic factors have been examined previously, data do not currently exist that examine the effects of hearing difficulties on PC skill or Internet use in older adults. Objective To explore the effect that hearing difficulty has on PC skill and Internet use in an opportunistic sample of adults aged 50-74 years. Methods Postal questionnaires about hearing difficulty, PC skill, and Internet use (n=3629) were distributed to adults aged 50-74 years through three family physician practices in Nottingham, United Kingdom. A subsample of 84 respondents completed a second detailed questionnaire on confidence in using a keyboard, mouse, and track pad. Summed scores were termed the “PC confidence index.” The PC confidence index was used to verify the PC skill categories in the postal questionnaire (ie, never used a computer, beginner, and competent). Results The postal questionnaire response rate was 36.78% (1298/3529) and 95.15% (1235/1298) of these contained complete information. There was a significant between-category difference for PC skill by PC confidence index (P<.001), thus verifying the three-category PC skill scale. PC and Internet use was greater in the younger respondents (50-62 years) than in the older respondents (63-74 years). The younger group’s PC and Internet use was 81.0% and 60.9%, respectively; the older group’s PC and Internet use was 54.0% and 29.8%, respectively. Those with slight hearing difficulties in the older group had significantly greater odds of PC use compared to those with no hearing difficulties (odds ratio [OR]=1.57, 95% confidence interval [CI] 1.06-2.30, P=.02). Those with moderate+ hearing difficulties had lower odds of PC use compared with those with no hearing difficulties, both overall (OR=0.58, 95% CI 0.39-0.87, P=.008) and in the younger group (OR=0.49, 95% CI 0.26-0.86, P=.008). Similar results were demonstrated for Internet use by age group (older: OR=1.57, 95% CI 0.99-2.47, P=.05; younger: OR=0.32, 95% CI 0.16-0.62, P=.001). Conclusions Hearing health care is of particular relevance to older adults because of the prevalence of age-related hearing loss. Our data show that older adults experiencing slight hearing difficulty have increased odds of greater PC skill and Internet use than those reporting no difficulty. These findings suggest that PC and Internet delivery of hearing screening, information, and intervention is feasible for people between 50-74 years who have hearing loss, but who would not typically present to an audiologist.

Auditory training can improve working memory, attention, and communication in adverse conditions for adults with hearing loss

Auditory training (AT) helps compensate for degradation in the auditory signal. A series of three high-quality training studies are discussed, which include, (i) a randomized controlled trial (RCT) of phoneme discrimination in quiet that trained adults with mild hearing loss (n = 44), (ii) a repeated measures study that trained phoneme discrimination in noise in hearing aid (HA) users (n = 30), and (iii) a double-blind RCT that directly trained working memory (WM) in HA users (n = 57). AT resulted in generalized improvements in measures of self-reported hearing, competing speech, and complex cognitive tasks that all index executive functions. This suggests that for AT related benefits, the development of complex cognitive skills may be more important than the refinement of sensory processing. Furthermore, outcome measures should be sensitive to the functional benefits of AT. For WM training, lack of far-transfer to untrained outcomes suggests no generalized benefits to real-world listening abilities. We propose that combined auditory-cognitive training approaches, where cognitive enhancement is embedded within auditory tasks, are most likely to offer generalized benefits to the real-world listening abilities of adults with hearing loss.

The relationship of speech intelligibility with hearing sensitivity, cognition, and perceived hearing difficulties varies for different speech perception tests.

Listeners vary in their ability to understand speech in noisy environments. Hearing sensitivity, as measured by pure-tone audiometry, can only partly explain these results, and cognition has emerged as another key concept. Although cognition relates to speech perception, the exact nature of the relationship remains to be fully understood. This study investigates how different aspects of cognition, particularly working memory and attention, relate to speech intelligibility for various tests. Perceptual accuracy of speech perception represents just one aspect of functioning in a listening environment. Activity and participation limits imposed by hearing loss, in addition to the demands of a listening environment, are also important and may be better captured by self-report questionnaires. Understanding how speech perception relates to self-reported aspects of listening forms the second focus of the study. Forty-four listeners aged between 50 and 74 years with mild sensorineural hearing loss were tested on speech perception tests differing in complexity from low (phoneme discrimination in quiet), to medium (digit triplet perception in speech-shaped noise) to high (sentence perception in modulated noise); cognitive tests of attention, memory, and non-verbal intelligence quotient; and self-report questionnaires of general health-related and hearing-specific quality of life. Hearing sensitivity and cognition related to intelligibility differently depending on the speech test: neither was important for phoneme discrimination, hearing sensitivity alone was important for digit triplet perception, and hearing and cognition together played a role in sentence perception. Self-reported aspects of auditory functioning were correlated with speech intelligibility to different degrees, with digit triplets in noise showing the richest pattern. The results suggest that intelligibility tests can vary in their auditory and cognitive demands and their sensitivity to the challenges that auditory environments pose on functioning.

Understanding the psychosocial experiences of adults with mild-moderate hearing loss: An application of Leventhal's self-regulatory model.

Abstract Objective: This study explored the psychosocial experiences of adults with hearing loss using the self-regulatory model as a theoretical framework. The primary components of the model, namely cognitive representations, emotional representations, and coping responses, were examined. Design: Individual semi-structured interviews were conducted. The data were analysed using an established thematic analysis procedure. Study sample: Twenty-five adults with mild-moderate hearing loss from the UK and nine hearing healthcare professionals from the UK, USA, and Canada were recruited via maximum variation sampling. Results: Cognitive representations: Most participants described their hearing loss as having negative connotations and consequences, although they were not particularly concerned about the progression or controllability/curability of the condition. Opinions differed regarding the benefits of understanding the causes of one’s hearing loss in detail. Emotional representations: negative emotions dominated, although some experienced positive emotions or muted emotions. Coping responses: engaged coping (e.g. hearing aids, communication tactics) and disengaged coping (e.g. withdrawal from situations, withdrawal within situations): both had perceived advantages and disadvantages. Conclusions: This novel application of the self-regulatory model demonstrates that it can be used to capture the key psychosocial experiences (i.e. perceptions, emotions, and coping responses) of adults with mild-moderate hearing loss within a single, unifying framework.

Applying theories of health behaviour and change to hearing health research: Time for a new approach

Abstract Objective: In recent years, there has been an increase in the application of behavioural models, such as social cognition models, to the promotion of hearing health. Despite this, there exists a well-developed body of literature that suggests such models may fail to consistently explain reliable amounts of variability in human behaviours. Design: This paper provides a summary of this research across selected models of health-related behaviour, outlining the current state of the evidence. Results: Recent work in the field of behaviour change is presented together with commentary on the design and reporting of behaviour change interventions. Conclusions: We propose that attempts to use unreliable models to explain and predict hearing health behaviours should now be replaced by work which integrates the latest in behaviour change science, such as the Behaviour Change Wheel and Theoretical Domains Framework.

Only Behavioral But Not Self-Report Measures of Speech Perception Correlate with Cognitive Abilities

Good speech perception and communication skills in everyday life are crucial for participation and well-being, and are therefore an overarching aim of auditory rehabilitation. Both behavioral and self-report measures can be used to assess these skills. However, correlations between behavioral and self-report speech perception measures are often low. One possible explanation is that there is a mismatch between the specific situations used in the assessment of these skills in each method, and a more careful matching across situations might improve consistency of results. The role that cognition plays in specific speech situations may also be important for understanding communication, as speech perception tests vary in their cognitive demands. In this study, the role of executive function, working memory (WM) and attention in behavioral and self-report measures of speech perception was investigated. Thirty existing hearing aid users with mild-to-moderate hearing loss aged between 50 and 74 years completed a behavioral test battery with speech perception tests ranging from phoneme discrimination in modulated noise (easy) to words in multi-talker babble (medium) and keyword perception in a carrier sentence against a distractor voice (difficult). In addition, a self-report measure of aided communication, residual disability from the Glasgow Hearing Aid Benefit Profile, was obtained. Correlations between speech perception tests and self-report measures were higher when specific speech situations across both were matched. Cognition correlated with behavioral speech perception test results but not with self-report. Only the most difficult speech perception test, keyword perception in a carrier sentence with a competing distractor voice, engaged executive functions in addition to WM. In conclusion, any relationship between behavioral and self-report speech perception is not mediated by a shared correlation with cognition.

Computer and Internet Interventions to Optimize Listening and Learning for People With Hearing Loss: Accessibility, Use, and Adherence

PURPOSE The aim of this research forum article was to examine accessibility, use, and adherence to computerized and online interventions for people with hearing loss. METHOD Four intervention studies of people with hearing loss were examined: 2 auditory training studies, 1 working memory training study, and 1 study of multimedia educational support. RESULTS A small proportion (approximately 15%) of participants had never used a computer, which may be a barrier to the accessibility of computer and Internet-based interventions. Computer competence was not a factor in intervention use or adherence. Computer skills and Internet access influenced participant preference for the delivery method of the multimedia educational support program. CONCLUSIONS It is important to be aware of current barriers to computer and Internet-delivered interventions for people with hearing loss. However, there is a clear need to develop and future-proof hearing-related applications for online delivery.

How Does Auditory Training Work? Joined-Up Thinking and Listening

Auditory training aims to compensate for degradation in the auditory signal and is offered as an intervention to help alleviate the most common complaint in people with hearing loss, understanding speech in a background noise. Yet there remain many unanswered questions. This article reviews some of the key pieces of evidence that assess the evidence for whether, and how, auditory training benefits adults with hearing loss. The evidence supports that improvements occur on the trained task; however, transfer of that learning to generalized real-world benefit is much less robust. For more than a decade, there has been an increasing awareness of the role that cognition plays in listening. But more recently in the auditory training literature, there has been an increased focus on assessing how cognitive performance relevant for listening may improve with training. We argue that this is specifically the case for measures that index executive processes, such as monitoring, attention switching, and updating of working memory, all of which are required for successful listening and communication in challenging or adverse listening conditions. We propose combined auditory-cognitive training approaches, where training interventions develop cognition embedded within auditory tasks, which are most likely to offer generalized benefits to the real-world listening abilities of people with hearing loss.