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Galvin K, Tomlin D, Timmer BHB, McNeice Z, Mount N, Gray K, Short CE. Consumer Perspectives for a Future Mobile App to Document Real-World Listening Difficulties: Qualitative Study. JMIR Form Res 2024; 8:e47578. [PMID: 39042452 PMCID: PMC11303898 DOI: 10.2196/47578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 10/11/2023] [Accepted: 04/14/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND By enabling individuals with hearing loss to collect their own hearing data in their personal real-world settings, there is scope to improve clinical care, empower consumers, and support shared clinical decision-making and problem-solving. Clinician support for this approach has been established in a separate study. OBJECTIVE This study aims to explore, for consumers with hearing loss, their (1) experiences of listening difficulties, to identify the data an app could usefully collect; (2) preferences regarding the features of mobile apps in general; and (3) opinions on the potential value and desirable features of a yet-to-be designed app for documenting listening difficulties in real-world settings. METHODS A total of 3 focus groups involved 27 adults who self-reported hearing loss. Most were fitted with hearing devices. A facilitator used a topic guide to generate discussion, which was video- and audio-recorded. Verbatim transcriptions were analyzed using inductive content analysis. RESULTS Consumers supported the concept of a mobile app that would facilitate the documenting of listening difficulties in real-world settings important to the individual. Consumers shared valuable insights about their listening difficulties, which will help determine the data that should be collected through an app designed to document these challenges. This information included early indicators of hearing loss (eg, mishearing, difficulty communicating in groups and on the phone, and speaking overly loudly) and prompts to seek hearing devices (eg, spousal pressure and the advice or example provided by others, and needing to rely on lipreading or to constantly request others to repeat themselves). It also included the well-known factors that influence listening difficulties (eg, reverberation, background noise, group conversations) and the impacts and consequences of their difficulties (eg, negative impacts on relationships and employment, social isolation and withdrawal, and negative emotions). Consumers desired a visual-based app that provided options for how data could be collected and how the user could enter data into an app, and which enabled data sharing with a clinician. CONCLUSIONS These findings provide directions for the future co-design and piloting of a prototype mobile app to provide data that are useful for increasing self-awareness of listening difficulties and can be shared with a clinician.
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Affiliation(s)
- Karyn Galvin
- Department of Audiology and Speech Pathology, University of Melbourne, Carlton, Australia
| | - Dani Tomlin
- Department of Audiology and Speech Pathology, University of Melbourne, Carlton, Australia
| | - Barbra H B Timmer
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
- Sonova AG, Staefa, Switzerland
| | - Zoe McNeice
- Department of Audiology and Speech Pathology, University of Melbourne, Carlton, Australia
| | - Nicole Mount
- Department of Audiology and Speech Pathology, University of Melbourne, Carlton, Australia
| | - Kathleen Gray
- Centre for Digital Transformation of Health, University of Melbourne, Carlton, Australia
| | - Camille E Short
- Melbourne Centre for Behaviour Change, Melbourne School of Psychological Sciences, University of Melbourne, Carlton, Australia
- Melbourne School of Health Sciences, University of Melbourne, Carlton, Australia
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Feenstra-Kikken V, Van de Ven S, Lissenberg-Witte BI, Pronk M, Smits C, Timmer BHB, Polleunis C, Besser J, Kramer SE. Effectiveness of the HEAR-Aware App for Adults Not Ready for Hearing Aids, but Open to Self-Management Support: Results of a Randomized Controlled Trial. Ear Hear 2024:00003446-990000000-00294. [PMID: 38831480 DOI: 10.1097/aud.0000000000001533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
INTRODUCTION Recently, the HEAR-aware app was developed to support adults who are eligible for hearing aids (HAs) but not yet ready to use them. The app serves as a self-management tool, offering assistance for a range of target behaviors (TBs), such as communication strategies and emotional coping. Using ecological momentary assessment and intervention, the app prompts users to complete brief surveys regarding challenging listening situations they encounter in their daily lives (ecological momentary assessment). In response, users receive educational content in the form of "snippets" (videos, texts, web links) on the TBs, some of which are customized based on the reported acoustic environmental characteristics (ecological momentary intervention). The primary objective of this study was to assess the effectiveness of the HEAR-aware app in enhancing readiness to take action on various TBs and evaluate its impact on secondary outcomes. The secondary objective was to examine the app's usability, usefulness, and user satisfaction. METHODS A randomized controlled trial design with two arms was used. Participants with hearing loss aged 50 years and over were recruited via an HA retailer and randomly assigned to the intervention group (n = 42, mean age = 65 years [SD = 9.1]) or the control group (n = 45, mean age = 68 years [SD 8.7]). The intervention group used the app during 4 weeks. The control group received no intervention. All participants completed online questionnaires at baseline (T0), after 4 weeks (T1), and again 4 weeks later (T2). Participants' readiness to take action on five TBs was measured with The Line Composite. A list of secondary outcomes was used. Intention-to-treat analyses were performed using Linear Mixed effect Models including group (intervention/control), time (T0/T1/T2), and Group × Time Interactions. In addition, a per protocol analysis was carried out to explore whether effects depended on app usage. For the secondary aim the System Usability Scale (SUS), the Intrinsic Motivation Inventory, item 4 of the International Outcome Inventory-Alternative Intervention (IOI-AI), and a recommendation item were used (intervention group only at T1). RESULTS For objective 1, there was no significant group difference for The Line Composite over the course of T0, T1, and T2. However, a significant (p = 0.033) Group × Time Interaction was found for The Line Emotional coping, with higher increase in readiness to take action on emotional coping in the intervention group than in the control group. The intention-to-treat analyses revealed no other significant group differences, but the per protocol analyses showed that participants in the intervention group were significantly more ready to take up Assistive Listening Devices (The Line Assistive Listening Devices) and less ready to take up HAs (Staging Algorithm HAs) than the control group (p = 0.049). Results for objective 2 showed that on average, participants rated the app as moderately useful (mean Intrinsic Motivation Inventory score 5 out of 7) and its usability as "marginal" (mean SUS score 68 out of 100) with about half of the participants rating the app as "good" (SUS score >70) and a minority rating is as "unacceptable" (SUS score ≤50). DISCUSSION/CONCLUSIONS This study underscores the potential of self-management support tools like the HEAR-aware app in the rehabilitation of adults with hearing loss who are not yet ready for HAs. The range in usability scores suggest that it may not be a suitable intervention for everyone.
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Affiliation(s)
- Vanessa Feenstra-Kikken
- Department of Otolaryngology-Head and Neck Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Ear & Hearing, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Sjors Van de Ven
- Department of Otolaryngology-Head and Neck Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Ear & Hearing, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Birgit I Lissenberg-Witte
- Amsterdam University Medical Center Location Vrije Universiteit Amsterdam, Department of Epidemiology and Data Science, Amsterdam, the Netherlands
| | - Marieke Pronk
- Department of Otolaryngology-Head and Neck Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Ear & Hearing, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Cas Smits
- Amsterdam University Medical Center Location Universiteit van Amsterdam, Department of Otolaryngology-Head and Neck Surgery, Ear & Hearing, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Barbra H B Timmer
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Science and Technology, Sonova Aktien-gesellschaft, Stäfa, Switzerland
| | - C Polleunis
- Schoonenberg HoorSupport, Rotterdam, the Netherlands
| | - Jana Besser
- Science and Technology, Sonova Aktien-gesellschaft, Stäfa, Switzerland
| | - Sophia E Kramer
- Department of Otolaryngology-Head and Neck Surgery, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Ear & Hearing, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Timmer BHB, Bennett RJ, Montano J, Hickson L, Weinstein B, Wild J, Ferguson M, Holman JA, LeBeau V, Dyre L. Social-emotional well-being and adult hearing loss: clinical recommendations. Int J Audiol 2024; 63:381-392. [PMID: 36960799 DOI: 10.1080/14992027.2023.2190864] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/17/2023] [Accepted: 03/05/2023] [Indexed: 03/25/2023]
Abstract
Aim: Best-practice in audiological rehabilitation takes a holistic client- and family-centred approach and considers hearing care in the context of personal well-being. Hearing loss not only impairs the ability to hear, but can also compromise the ability to communicate, thus negatively impacting both social and emotional well-being. Hearing care professionals play a key role in fostering their client's well-being. This paper aims to provide evidence-based recommendations to ensure inclusion of social-emotional well-being in audiologic rehabilitation clinical practice.Methods: A review of current research and expert opinion.Results: This guide proposes a 5-step plan which includes: identifying the client's social-emotional well-being; including family members in audiological rehabilitation; incorporating social-emotional needs and goals in an individualized management plan; relating identified hearing needs and goals to rehabilitation recommendations; and using counselling skills and techniques to explore and monitor social-emotional well-being. Each component of the 5-step plan is discussed and clinical considerations are presented.Conclusion: These comprehensive recommendations provide guidance to hearing care professionals looking to ensure clients' social-emotional well-being are considered throughout the rehabilitation journey.
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Affiliation(s)
- Barbra H B Timmer
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia
- Sonova AG, Switzerland
| | - Rebecca J Bennett
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia
- Ear Science Institute Australia, Nedlands, Western Australia, Australia
- The Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Joseph Montano
- Weill Cornell Medicine, Department of Otolaryngology, New York, NY, USA
| | - Louise Hickson
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia
| | | | - Jane Wild
- Audiology Service, Betsi Cadwaladr University Health Board, Wales, UK
| | - Melanie Ferguson
- Ear Science Institute Australia, Nedlands, Western Australia, Australia
- School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Jack A Holman
- Hearing Sciences (Scottish Section), Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Valeri LeBeau
- Audiology Service, Advanced Bionics LLC, Valencia, USA
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Pronk M, Feenstra-Kikken V, Smits C, Besser J, Lissenberg-Witte BI, Polleunis C, Timmer BH, Kramer SE. Feasibility of the HEAR-aware App for Hearing Loss Self-Management: A Nonrandomized Intervention Study to Examine Intervention Acceptability and the Stages-of-Change Concept. Ear Hear 2024; 45:186-197. [PMID: 37677943 PMCID: PMC10718215 DOI: 10.1097/aud.0000000000001414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/17/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVES The HEAR-aware project targets adults ≥50 years who were recently diagnosed with hearing loss and declined hearing aids, but were open for support via a smartphone app on different target behaviors (TBs). The HEAR-aware app, based on Ecological Momentary Assessment and Ecological Momentary Intervention (EMA, EMI), contains educational materials ("snippets") tailored partly to the user's experienced listening situations. The app aims to increase adults' TB-specific readiness to take action on hearing problems. The present study focused on examining feasibility regarding three novel aspects: (1) the app's acceptability, mainly regarding its EMA and EMI elements (compliance, usability, usefulness, satisfaction), (2) psychometric properties of 10 new TB-specific stages-of-change (SoC) measures (test-retest reliability, construct validity), and (3) the potential of tailoring snippets on a person's SoC. DESIGN A nonrandomized intervention study including four measurements with 2-week intervals (T0-T3). (1) The intervention period lasted 4 weeks. App usage data were collected throughout (T1-T3). Usability, usefulness, and satisfaction were measured at T3 (n = 26). (2) Reliability concerned T0 and T1 data, in between which no intervention occurred. Intraclass correlation coefficients (ICCs) were calculated (n = 29). Construct validity was examined by calculating correlations between the different TB-specific scales (at T0), and also between each of them and self-reported hearing disability (n = 29). (3) Person-tailoring by SoC was examined using T0 and T1 data. Linear mixed models were applied to test whether users rated snippets corresponding to their SoC as more interesting and useful than noncorresponding snippets (n = 25). RESULTS (1) The percentage of participants that complied with the intended usage varied across the five predefined compliance criteria (lowest: 8%; highest: 85%). Median snippet satisfaction scores were reasonably positive (3.5 to 4.0 of 5). Usability was good (System Usability Score, mean = 72.4, SD = 14.3) and usefulness satisfactory (Intrinsic Motivation Inventory, mean = 4.4, SD = 1.4), but showed large variance. (2) The 10 TB-specific scales showed fair-to-excellent reliabilities (range ICCs = 0.51 to 0.80). Correlations between the TB-specific scales ranged between -0.17 ( p > 0.05) and 0.74 ( p < 0.001), supporting only partly overlap between their underlying constructs. Only the correlation between TB-specific readiness for hearing aid uptake and self-reported hearing disability was significant. (3) Correspondence of a snippet's SoC with the person's SoC significantly related to "interesting" ratings ( p = 0.006). Unexpectedly, for snippets with a lower SoC than the participant's, further deviation of the snippet's SoC from the participant's SoC, increased the participant's interest in the snippet. The relationship with "usefulness" was borderline significant. CONCLUSIONS (1) Overall usability, usefulness, and satisfaction scores indicated sufficient app acceptability. The high variance and fairly low compliance showed room for improving the app's EMA/EMI parts for part of the participants. (2) The 10 new TB-specific SoC measures showed sufficient reliability, supporting that they measured different types of readiness to take action on hearing problems (construct validity). (3) The unexpected findings regarding tailoring educational app materials to individuals' SoC deserve further study.
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Affiliation(s)
- Marieke Pronk
- Otolaryngology—Head and Neck Surgery, Section Ear and Hearing, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Vanessa Feenstra-Kikken
- Otolaryngology—Head and Neck Surgery, Section Ear and Hearing, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Cas Smits
- Otolaryngology—Head and Neck Surgery, Section Ear and Hearing, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | | | - Birgit I. Lissenberg-Witte
- Epidemiology & Data Science, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Conny Polleunis
- Sonova Audiological Care Nederland BV (Schoonenberg HoorSupport), Rotterdam, the Netherlands
| | - Barbra H.B. Timmer
- Sonova AG, Stäfa, Switzerland
- School of Health and Rehabilitation Sciences, The University of Queensland, St. Lucia, Brisbane, Australia
| | - Sophia E. Kramer
- Otolaryngology—Head and Neck Surgery, Section Ear and Hearing, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Brice S, Timmer BHB, Barr C. Centering on People: How Hearing Care Professionals Can Adapt to Consumers' Need and Outcomes. Semin Hear 2023; 44:274-286. [PMID: 37484985 PMCID: PMC10361789 DOI: 10.1055/s-0043-1769624] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023] Open
Abstract
Audiology is experiencing exponential growth in technology, service, and provision options. These advancements give hearing care professionals the opportunity to revise, potentially improve, and adapt to the modern hearing care landscape to better serve the modern consumer. Consumer needs guide care planning and delivery, with the goal of achieving outcomes that are important to both the consumer and the clinician. The changes available to the hearing care industry can also enable consumers' needs to be identified and served in a more holistic and personalized manner than has previously been possible. The purpose of this article is to explain and encourage hearing care professionals to adopt a mindset of doing whatever is reasonable and clinically appropriate to meet the need and desires of the consumer by implementing choice in service, technology, and channel across whichever model of care adopted by a provider.
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Affiliation(s)
- Sophie Brice
- Australian Institute for Health Service Management, COBE, University of Tasmania, Tasmania, Australia
| | - Barbra H. B. Timmer
- School of Health and Rehabilitation Sciences, University of Queensland, Queensland, Australia
- Sonova AG, Staefa, Switzerland
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Galvin KL, Timmer BHB, Tomlin D, Cleaver Z. Designing a Hearing Health Care Smartphone App With Ecological Momentary Assessment: A Qualitative Study of Audiologists' Perspectives. Am J Audiol 2022; 31:1247-1259. [DOI: 10.1044/2022_aja-22-00054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Purpose:
The purpose of this study was to explore the perspectives of audiologists to provide input into development of a smartphone application (app) to document the real-life listening difficulties and the listening environment of hearing aid candidates and users.
Method:
Two focus groups were conducted. Facilitators utilized a topic guide to generate participants' input and perspectives. The focus groups were audio-recorded and transcribed verbatim. The transcripts were then qualitatively analyzed using content analysis.
Study Sample:
The study samples were 10 audiologists (seven females) with 2- to 10-plus years of hearing aid fitting experience.
Results:
Three main categories were identified: (a) The mobile device app could provide meaningful information to help audiologists to counsel their clients, (b) the app could give clients an insight into their hearing difficulties, and (c) the app could help clients to self-manage their hearing condition.
Conclusion:
These findings suggest that audiologists may better understand their clients' real-life listening difficulties through the use of a mobile device app; however, further research is required to harness the benefits of such an app.
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Affiliation(s)
- Karyn L. Galvin
- Department of Audiology and Speech Pathology, School of Health Sciences, The University of Melbourne, Victoria, Australia
| | - Barbra H. B. Timmer
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Sonova AG, Stäfa, Switzerland
| | - Dani Tomlin
- Department of Audiology and Speech Pathology, School of Health Sciences, The University of Melbourne, Victoria, Australia
| | - Zuzana Cleaver
- Department of Audiology and Speech Pathology, School of Health Sciences, The University of Melbourne, Victoria, Australia
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Frisby C, Eikelboom R, Mahomed-Asmail F, Kuper H, Swanepoel DW. MHealth Applications for Hearing Loss: A Scoping Review. Telemed J E Health 2021; 28:1090-1099. [DOI: 10.1089/tmj.2021.0460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Caitlin Frisby
- Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
| | - Robert Eikelboom
- Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
- Ear Science Institute Australia, Subiaco, Australia
- Ear Sciences Centre, Medical School, The University of Western Australia, Nedlands, Australia
| | - Faheema Mahomed-Asmail
- Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
| | - Hannah Kuper
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - De Wet Swanepoel
- Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
- Ear Science Institute Australia, Subiaco, Australia
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Saunders GH, Vercammen C, Timmer BHB, Singh G, Pelosi A, Meis M, Launer S, Kramer SE, Gagné JP, Bott A. Changing the narrative for hearing health in the broader context of healthy living: a call to action. Int J Audiol 2021; 60:86-91. [PMID: 33794720 DOI: 10.1080/14992027.2021.1905892] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To discuss the steps necessary to facilitate hearing health care in the context of well-being and healthy living. DESIGN Common themes among the articles in this special supplement of the International Journal of Audiology were used to identify issues that must be addressed if audiology is to move from being hearing-focussed to taking a holistic perspective of hearing care in the context of healthy aging. These are discussed within the context of other published literature. RESULTS AND CONCLUSIONS Three needs were identified: (i) Increased interdisciplinary education to raise awareness of the interplay between hearing and health. (ii) Increased emphasis on counselling education in audiology programs so that audiologists are equipped with the knowledge, competence and confidence to provide counselling and emotional support to their patients, beyond care. (iii) Redefinition of therapeutic goal setting and hearing outcomes to include aspects of well-being, so that audiologists can capture and patients realise that that good hearing outcomes can have a direct positive impact on a person's quality of life that extends beyond their improved ability to hear. It was emphasised that each of these needs to be considered within the context of the audiologists' scope of practice and audiologists' well-being.
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Affiliation(s)
- Gabrielle H Saunders
- Manchester Centre for Audiology and Deafness, University of Manchester, Manchester, UK
| | | | - Barbra H B Timmer
- Sonova AG, Stafa, Switzerland.,School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia
| | - Gurjit Singh
- Phonak Canada, Mississauga, Canada.,Ryerson University, Toronto, Canada.,University of Toronto, Toronto, Canada
| | | | - Marcus Meis
- Hörzentrum Oldenburg gGmbH, Oldenburg, Germany.,Cluster of excellence Hearing4all, University of Oldenburg, Germany
| | - Stefan Launer
- Manchester Centre for Audiology and Deafness, University of Manchester, Manchester, UK.,Sonova AG, Stafa, Switzerland.,School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia
| | - Sophia E Kramer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Oldenburg, Netherlands.,Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Jean-Pierre Gagné
- École d'orthophonie et d'audiologie, Université de Montréal, Montréal, Canada.,Fondation Caroline Durand en audition et vieillissement de l'Universtié de Montréal, Montréal, Canada.,Centre de recherche de l'Institut universitaire de gériatrie de Montréal, Montréal, Canada
| | - Anthea Bott
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, Australia.,GN Hearing A/S, Ballerup, Denmark
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