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

Impact of adult cochlear implantation on the partner relationship: a conceptual framework informed by cochlear implant recipient and partner perceptions

PURPOSE

(1) To understand the impact of adult cochlear implantation on the partner relationship, as perceived by adult cochlear implant (CI) recipients and their intimate partners. (2) To generate a conceptual framework for guiding future research and clinical adult cochlear implantation interventions.

METHOD

Concept mapping, a participatory, mixed-method approach, was used for data collection, analysis and interpretation. Participants attended sessions to generate, sort and rate statements describing the changes in their relationship due to cochlear implantation. Participants included 15 CI recipients (mean age: 51.6 years; SD: 8.2) and 12 partners (mean age: 50.9 years; SD: 8.2).

RESULTS

Five concepts emerged from the data, describing changes in the partner relationship following cochlear implantation: (1) Social Interactions, (2) Partner Involvement, (3) Communication, (4) Emotional Adjustment, and (5) Relationship Intimacy. The concept Relationship Intimacy was rated the highest in positivity and importance. Findings also underscored improved social interactions, communication dynamics, and emotional adjustment.

CONCLUSIONS

The Relationship Intimacy cluster emerged as pivotal, highlighting its essential role in improving post-implantation relationships. CI recipients experienced enhanced autonomy, while partners' roles evolved regarding assistance and support. The diverse effects of implantation on partner relationships highlight the importance of adopting a patient- and family-centered approach to audiological intervention.

Factors Influencing Intentions of People with Hearing Impairments to Use Augmented Reality Glasses as Hearing Aids

The advent and progression of AR (augmented reality) technology, coupled with the emergence of AR hearing aid glasses, offer a novel opportunity for people with hearing impairments (PHI). This study aims to explore the intention of this population to employ AR hearing aid glasses as their choice of hearing aid device and the specific factors influencing their preference. This study utilized the partial least squares SEM (PLS-SEM) analytical method to create structural equation model for intentions of PHI to use AR glasses as hearing aids. Data were gathered from on-site experiences across multiple locations; a total of 189 valid questionnaires from individuals with varying degrees of hearing disabilities were used for statistical analysis. According to the data analysis results, we discovered that functionality quality, perceived interaction speed, and perceived usability significantly influence communication effectiveness. Further, communication effectiveness positively influences confidence and societal perception, and the latter has a positive impact on information. Both of these factors positively influence behavioral intention. Based on these findings, this study offers design recommendations for AR hearing aid glasses to cater to the specific needs of PHI, aiming to enhance their quality of life. Furthermore, this study provides pivotal insights for the prospective growth of this emerging industry.

Diabetes mellitus, hearing loss, and therapeutic interventions: A systematic review of insights from preclinical animal models

OBJECTIVES

The aim of this systematic review article is to evaluate the relationship between diabetes mellitus (DM) and sensorineural hearing loss (SNHL) utilizing preclinical animal models. The review focused on studies assessing SNHL in diabetic animal models, elucidating the mechanisms of DM-associated SNHL, and exploring the response of diabetic animal models to noise overexposure. We also discussed studies investigating the efficacy of potential therapeutic strategies for amelioration of DM-associated SNHL in the animal models.

METHODS

A protocol of this systematic review was designed a priori and was registered in the PROSPERO database (registration number: CRD42023439961). We conducted a comprehensive search on PubMed, Science Direct, Web of Science, Scopus, and EMBASE databases. A minimum of three reviewers independently screened, selected, and extracted data. The risk of bias assessment of eligible studies was conducted using the Systematic Review Center for Laboratory Animal Experimentation (SYRCLE) tool.

RESULTS

Following the screening of 238 studies, twelve original articles were included in this systematic review. The studies revealed that hyperglycemia significantly affects auditory function, with various pathological mechanisms contributing to DM-induced hearing impairment, including cochlear synaptopathy, microangiopathy, neuropathy, oxidative stress, mitochondrial abnormalities, and apoptosis-mediated cell death. Emerging interventions, such as Asiaticoside, Trigonelline, Chlorogenic acid, and Huotanquyu granules, demonstrated efficacy in providing otoprotection for preserving cochlear hair cells and hearing function.

CONCLUSIONS

Our systematic review delves into the intricate relationship between DM and hearing impairment in animal models. Future research should focus on targeted therapies to enhance cochlear mitochondrial function, alleviate oxidative stress, and regulate apoptosis. The association between SNHL and social isolation as well as cognitive decline underscores the necessity for innovative therapeutic modalities addressing yet undiscovered mechanisms. Translating findings from animal models to human studies will validate these findings, offering a synergistic approach to effectively manage DM-associated co-morbidities such as hearing impairment.

What impact does hearing impairment have on cognitive health in older married couples in China?

Hearing impairment is a common geriatric health problem and chronic stressor, and it is associated with poor cognitive outcomes. However, little is known about the impact of hearing impairment in married couples, particularly its potential spillover effects on the cognitive health among spouses of individuals with impairment. Drawing on a stress-proliferation perspective, we used actor-partner interdependence models to examine (1) whether an individual's hearing impairment influences their spouse's cognitive function; and (2) whether AL, symptoms of depression, and social participation serve as mediators for such an association. We utilized data from the 2015 (baseline) and 2018 (3-year follow-up) waves of the China Health and Retirement Longitudinal Study. 4434 couples were included at baseline, and 2190 couples remained after the 3-year follow-up. Hearing impairment among married women was associated with negative impacts on their spouses' cognitive function. Symptoms of depression and social participation may have served as potential mediators in this relationship. For married men, there was no statistically significant association between hearing impairment and spouses' cognitive function. Our findings suggest that hearing impairment among one spouse can lead to negative impacts on the other, but that this effect may depend on gender. Early diagnosis and couple-based interventions for hearing impairment are important for the cognitive health of both hearing-impaired individuals and their spouses.

Illness perceptions of people living with chronic heart failure and limited community disease management

AIM

To explore the cognitive representations and emotional responses to living with chronic heart failure of people receiving limited community disease management.

BACKGROUND

Individuals living with heart failure face self-care and emotional challenges due to the overwhelming nature of adapting to lifestyle changes, particularly in subtropical areas.

DESIGN

Qualitative descriptive. We applied Leventhal's Common Sense Model of Self-Regulation as the framework for interviews and analyses.

METHODS

Twenty patients with chronic heart failure were interviewed during a hospital admission for exacerbation of their condition in a tertiary hospital in Thailand.

RESULTS

Analysis of the components of Leventhal's model of cognitive representations of illness revealed two themes relating to Illness Identity: (1) lack of knowledge of the diagnosis and how to recognise symptoms of the disease, and (2) recognition of symptoms of an exacerbation of CHF was based on past experience rather than education. These resulted in delays responding to cardiac instability and confusion about the intent of treatment. Participants recognised the chronicity of their disease but experienced it as an unrelenting cycle of relative stability and hospitalisations. Perceived Controllability was low. Two themes were: (1) Low perceived trust in the efficacy of medical treatment and lifestyle changes, and (2) Low perceived trust in their ability to comply with recommended lifestyle changes. The Consequences were significant emotional distress and high burden of disease. The two themes of emotional responses were (1) Frustration and hopelessness with the uncertainty and unpredictability of the disease, and (2) Sense of loss of independence, functional capacity and participation in life's activities.

CONCLUSION

Chronically ill patients need support to understand their illness and make better treatment and lifestyle decisions. Improving patients' self-efficacy to manage treatment and symptom fluctuations has the potential to improve their mental well-being and minimise the impact of their condition on suffering and participation in employment and community.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Leventhal's Common Sense Model of Self-Regulation can be used to examine cognitive and emotional elements of illness perceptions, which link to individuals' ability to make informed decisions about disease management and influence health behaviours. Understanding illness perceptions underpins strategies for enhancing and sustaining self-management behaviours.

IMPACT

The study findings accentuate the need to establish long-term condition support programs in low-middle income countries where the burden of heart failure is increasing exponentially.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline was used to explicitly and comprehensively report our qualitative research.

PATIENT OR PUBLIC CONTRIBUTION

Patients contributed to the conduct of the study by participating in the data collection via face-to-face interviews.

Social-emotional well-being and adult hearing loss: clinical recommendations

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.

Adults' recollections of discussions with their audiologist: a qualitative study of what was and was not successfully communicated about listening difficulties

OBJECTIVES

Some adults experience challenges in successfully communicating their listening difficulties to their audiologist, and report feeling that they are not always listened to or understood. This project examined adults' recollections of discussions with their audiologist to explore (1) how adults report describing their listening difficulties and (2) information that adults report they do not communicate, or do not communicate successfully, to their audiologist.

DESIGN

Individual semi-structured interviews were conducted. Interview transcripts were analysed using a template analysis approach.

STUDY SAMPLE

Fifteen adults who self-report listening difficulties, and who had previously consulted an audiologist.

RESULTS

Four themes were identified from adults' recollections of how they describe their listening difficulties: (1) situation or context of listening difficulties, (2) behavioural responses, (3) impacts of listening difficulties and (4) contributing factors. Adults report not always successfully communicating (1) emotional concerns and impacts, (2) descriptions of sound quality and (3) descriptions of changed listening experiences.

CONCLUSION

Results provide insights about the times when adults feel that communication with their audiologist is successful, or unsuccessful. The results are useful for informing interventions to help adults and audiologists communicate more effectively together. To further inform interventions, factors affecting adults' communication should be explored.

Evaluation of the Ask-Inform-Manage-Encourage-Refer Intervention and Its Implementation Targeting the Provision of Mental Wellbeing Support Within the Audiology Setting

OBJECTIVES

The ask, inform, manage, encourage, refer (AIMER) program is a behavior change intervention designed to increase the frequency with which hearing healthcare clinicians (HHCs) ask about and provide information regarding mental wellbeing within adult audiology services. The objective of this study was to systematically evaluate the first iteration of the AIMER program to determine whether the intervention achieved the changes in HHC behaviors anticipated and to evaluate feasibility of implementing the AIMER program based on the implementation protocol.

DESIGN

The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to guide this evaluation. Data were collected from October 2020 to February 2022 and included both quantitative and qualitative measures (i.e., observation reports, staff surveys, clinical diaries, clinical file audits, and interviews).

RESULTS

Comparison between pre- and post-implementation data showed that the AIMER intervention successfully increased: (i) HHC's skills and confidence for discussing mental wellbeing; (ii) how often HHCs ask about mental wellbeing within audiology consultations; (iii) how often HHCs provide personalized information and support regarding mental wellbeing within audiology consultations; and (iv) how often HHCs use mental wellbeing terms within clinical case notes and general practitioner reports. The factors affecting feasibility of implementing the AIMER program within the clinical setting could be classified into three major categories: (i) the AIMER program itself and its way of delivery to clinical staff; (ii) people working with the AIMER program; and (iii) contextual factors. Key recommendations to improve future implementation of the AIMER program were provided by the participants.

CONCLUSIONS

The AIMER program was shown to be effective at increasing the frequency with which HHCs ask about and provide information regarding mental wellbeing within routine audiological service delivery. Implementation of the AIMER program was feasible but leaves room for improvement. Use of the reach, effectiveness, adoption, implementation, and maintenance framework facilitated systematic evaluation of multiple indicators providing a broad evaluation of the AIMER program. Our analysis helps to better understand the optimal levels of training and facilitation and provides recommendations to improve future scale-up of the AIMER program. The findings of this study will be used to further adapt and improve the AIMER program and to enhance program implementation strategies before its further dissemination.

Applications of Grounded Theory Methodology to Investigate Hearing Loss: A Methodological Qualitative Systematic Review With Developed Guidelines

OBJECTIVES

Qualitative methodologies are commonly adopted in hearing loss research. Grounded theory methodology is increasingly used to establish novel theories explaining experiences related to hearing loss. Establishing and improving the quality of grounded theory studies has been emphasized as critical to ensuring theoretical trustworthiness. Thus, the primary aim of the present study was to systematically review hearing loss research studies that have applied grounded theory methodology and assess the methodological quality of those grounded theory applications. Secondarily aims were to (i) explore how grounded theory methodology has been applied to investigate hearing loss, and (ii) use the findings of the review to develop a set of guidelines to aid the future high-quality application of grounded theory methodology to hearing loss research.

DESIGN

Original peer-reviewed studies applying grounded theory methodology and published in English were identified through systematic searches in 10 databases; Applied Social Sciences Index and Abstracts, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, EBSCO, Global Health, MEDLINE (OvidSP), PsycINFO, PubMed, Scopus, and Web of Science. The quality of studies was assessed according to 12 grounded theory principles using the Guideline for Reporting, Evaluating, and applying the core principles of Grounded Theory studies (GUREGT) tool. Data were analyzed using qualitative inductive thematic analysis.

RESULTS

After the removal of duplicates, 155 articles were retrieved. Of those, 39 met the criteria for inclusion in the systematic review. An increase in the adoption of grounded theory methodology to investigate hearing loss was identified with the number of published studies tripling in the last 5 years. Critical appraisal using the GUREGT tool identified four studies as high-quality. Most included studies were of moderate study quality (n = 25), and 10 were classified as being of low study quality. Using inductive thematic analysis, the included studies investigated one of four areas relating to hearing loss: (a) Living with hearing loss, (b) Identity and hearing loss, (c) Coping strategies for hearing loss, and (d) Audiological counseling and rehabilitation. Analysis also identified four main grounded theory factors frequently overlooked in hearing loss research: the different schools of grounded theory, sampling strategy, sample size, and the depth of grounded theory application.

CONCLUSIONS

Use of grounded theory methodology is increasing at a rapid rate in hearing loss research. Despite this, studies conducted in the field to date do not meet and apply the full spectrum of grounded theory principles, as outlined by the GUREGT tool. To improve methodological rigor in future studies using grounded theory, we propose a set of guidelines that address the most commonly overlooked methodological considerations in hearing loss studies to date. The guidelines are designed to aid researchers to achieve high methodological quality in any field, improve qualitative rigor, and promote theoretical credibility.

Development of a self-report measure of empowerment along the hearing health journey: a content evaluation study

OBJECTIVE

To conduct the first phases in the development of a self-report measure of empowerment on the hearing health journey, specifically, item generation and content evaluation of the initial pool of items generated.

DESIGN

A content expert panel survey and cognitive interviews were conducted. Descriptive statistics were obtained for the quantitative data, and the cognitive interviews were analysed using thematic analysis.

STUDY SAMPLE

Eleven researchers and clinicians participated in the content expert surveys. Sixteen experienced hearing aid users participated in the cognitive interviews, recruited from the USA and Australia.

RESULTS

The items underwent five iterations based on feedback from the survey and interview data. This resulted in a set of 33 quality-tested potential survey items that were rated highly for relevance (mean = 3.96), clarity (mean = 3.70) and fit to dimensions of empowerment (mean = 3.92) (scale 0-4, where 4 was the maximum rating).

CONCLUSIONS

Involving stakeholders in item generation and content evaluation increased relevance, clarity, fit to dimension, comprehensiveness, and acceptability of the items. This preliminary version of the 33-item measure underwent further psychometric refinement (Rasch analysis and traditional classical test theory testing) to validate it for clinical and research use (reported separately).

A scoping review exploring how adults self-describe and communicate about the listening difficulties they experience

Objective: It is unknown how adults communicate about their experienced listening difficulties with their audiologist. This scoping review aims to explore how adults self-describe the listening difficulties that they experience, and how they communicate about them. Design: A scoping review was conducted between December 2020 and September 2022 to identify published journal articles in which adults described and communicated about their listening difficulties. Study sample: Database searches yielded 10,224 articles initially. After abstract screening and full text review, 55 articles were included for analysis. Results: The listening difficulties that adults described were varied, highlighting the fact that each person has individual experiences. Adults discussed reasons for their listening difficulties, impacts of their listening difficulties, and behavioural responses they adopted to cope with their listening difficulties. Conclusions: This review shows the broad impacts of listening difficulties, and the varied ways in which adults discuss their listening difficulties. There is no available literature reporting how adults communicate about their listening difficulties in a clinical context.

Associations between illness perceptions, word recognition, and perceived sound quality in cochlear implant users

OBJECTIVE

Illness perceptions refer to thoughts and ideas an individual has about an illness. The aim was to understand how cochlear implant (CI) users' illness perceptions, in addition to their monosyllabic word recognition abilities, are associated with their self-perceived sound quality.

DESIGN

Data were collected during routine CI check-up appointments. Participants completed the Brief Illness Perception Questionnaire (assessing their illness perceptions) and the Hearing Implant Sound Quality Index (assessing their subjective sound quality). Additionally, monosyllabic word recognition abilities were measured with the Freiburg Monosyllable Word Test. Hierarchical regression analysis were utilised to model users' sound quality ratings. Participants' age was entered first as a control variable. In the next step, monosyllabic word recognition was entered. Finally, participants' illness perceptions were entered.

STUDY SAMPLE

Fifty-five participants with unilateral CI provision.

RESULTS

Monosyllabic word recognition was significant in the second step. When illness perceptions and monosyllabic word recognition were both included in the third step, illness perceptions, but not monosyllabic word recognition, were significant. The model explained 22% of the variance of subjective sound quality.

CONCLUSIONS

Monosyllabic word recognition abilities and illness perceptions of CI users are important for their self-reported sound quality, but illness perceptions appear to be potentially more relevant.

Influence of Hearing Loss on Social Participation in Older Adults: Results From a Scoping Review

This study aimed to provide a comprehensive understanding of the influence of hearing loss on social participation in older adults and including its facilitators and barriers. Following the rigorous methodological framework of scoping studies, nine multidisciplinary databases were searched with 44 keywords. Published mainly in the last decade, 41 studies using primarily a quantitative cross-sectional design were selected. Older adults with hearing loss have been found to have difficulty maintaining relationships and social activities. While social support and engaged-coping strategies were major facilitators of social participation, barriers included greater hearing loss, communication difficulties, comorbidities and reduced mental health. To better promote the social participation of older adults, early detection of hearing loss, holistic assessment, and interprofessional collaboration must be considered. Future research is necessary to better address the stigma related to hearing loss in older adults and challenges of early detection, and to propose innovative solutions to develop interprofessional collaboration.

Impact of hearing loss on cognitive function in community-dwelling older adults: serial mediation of self-rated health and depressive anxiety symptoms

Background

Hearing loss can exacerbate cognitive decline; therefore, exploring the mechanisms through which hearing loss affects cognitive function is crucial. The current study aimed to investigate the impact of hearing loss on cognitive function and the mediating role played by self-rated health and depressive anxiety symptoms.

Methods

Using stratified whole-group random sampling, the study employed a cross-sectional design and included 624 participants aged ≥65 years from three communities in Urumqi, China. Cognitive function was assessed using the Mini-Mental State Examination. Hearing function and self-rated health were determined by self-report. The 15-item Geriatric Depression Scale and the 7-item Generalized Anxiety Disorder Scale were used to assess depressive anxiety symptoms. Serial mediation analysis was performed using AMOS 26.0.

Results

Hearing loss can not only negatively affect cognitive function in older adults directly (direct effect = -0.106; SE = 0.045; 95% confidence interval (CI): -0.201 to -0.016), but also indirectly affect the relationship between hearing loss and cognitive function through self-rated health and depressive anxiety symptoms. The results of the serial mediation analysis showed that the total indirect effect of self-rated health and depressive anxiety symptoms was -0.115 (95% CI: -0.168 to -0.070), and the total effect of the model was -0.221 (95% CI: -0.307 to -0.132), with the total indirect effect accounting for 52.04% of the total effect of the model.

Conclusion

Our study discovered that there is a partial mediation of the relationship between hearing loss and cognitive function by self-rated health and depressive anxiety symptoms. It is suggested that by enhancing self-rated health and ensuring good mental health, the decline in cognitive function among older adults with hearing loss can be delayed.

Protocol for the development and validation of a patient-reported experience measure (PREM) for people with hearing loss: the PREM-HeLP

INTRODUCTION

Hearing loss is a common chronic health condition and adversely affects communication and social function resulting in loneliness, social isolation and depression. We know little about the patient experience of living with hearing loss and their views on the quality of the audiology service. In this study, we will develop and validate the first patient-reported experience measure (PREM) to understand patients' experiences of living with hearing loss and their healthcare interactions with audiology services.

METHODS AND ANALYSIS

We will develop the PREM in three phases: (1) development of PREM prototype (items/statements) derived from previous qualitative work and narrative review, (2) cognitive interview testing of the PREM prototype using a 'think aloud' technique to examine the acceptability and comprehensibility of the tool and refine accordingly and (3) psychometric testing of the modified PREM with 300 participants to assess the reliability and validity of the tool using Rasch analyses with sequential item reduction. Eligible participants will be young people and adults aged 16 years and over who have hearing loss. Participants will be recruited from three clinical sites located in England (Bath, Bristol) and Scotland (Tayside) and non-clinical settings (eg, lip-reading classes, residential care settings, national charity links, social media).

ETHICS AND DISSEMINATION

The study was approved by the West of Scotland Research Ethics Service (approval date: 6 May 2022; ref: 22/WS/0057) and the Health Research Authority and Health and Care Research Wales (HCRW) Approval (approval date: 14 June 2022; IRAS project ID: 308816). Findings will be shared with our patient and public involvement groups, academics, audiology communities and services and local commissioners via publications and presentations. The PREM will be made available to clinicians and researchers without charge.

The Self-Stigma of Hearing Loss in Adults and Older Adults: A Systematic Review

OBJECTIVES

Previous studies have demonstrated that individuals with hearing loss can internalize social stigmas, resulting in several self-perceived negative connotations, such as incompetence, cognitive impairment, and social disability. This systematic review aimed to investigate the impact of the social stigma associated with hearing loss on the self-stigma experienced by adults and older adults.

DESIGN

Combinations of words and appropriate truncations were selected and adjusted specifically for each electronic database. The Population, Exposure, Comparator, Outcomes, and Study Characteristics strategy was used to delimit the scope of the review, bearing in mind the importance of a well-formulated research question.

RESULTS

A total of 953 articles were retrieved from the final search of each database. Thirty-four studies were selected for full-text reading. Thirteen were excluded, and 21 studies were ultimately included in this review. The results of this review were divided into three themes: (1) impact of social stigmas on self-stigma, (2) effect of emotions on self-stigma, and (3) other factors that impact self-stigma. The themes were related to the relationship between the individual and social perceptions reported by the participants with respect to their hearing experiences.

CONCLUSIONS

Our results suggest that the impact of social stigma associated with hearing loss on the self-stigma of adults and older adults is strongly associated with the effects of aging and hearing loss, which may lead to withdrawal, social segregation, and negative self-perception.

A qualitative investigation of the hearing and hearing-aid related emotional states experienced by adults with hearing loss

OBJECTIVE

Despite previous research into the psychosocial impact of hearing loss, little detail is known regarding the hearing and hearing-aid-related emotional states experienced by adults with hearing loss in everyday life, and how they occur.

DESIGN

Individual remote semi-structured interviews were audio-recorded, transcribed verbatim and qualitatively analysed with reflexive and inductive thematic analysis.

STUDY SAMPLE

Seventeen participants (9 female) with hearing loss (age range 44-74 years) participated. Ten used bilateral hearing aids, four unilateral and three used no hearing aids at the time of interviews.

RESULTS

The four main themes which emerged from the data were: identity and self-image, autonomy and control, personality and dominant emotional states and situational cost/benefit analysis with respect to use of hearing aids.

CONCLUSIONS

This study goes beyond previous literature by providing a more detailed insight into emotions related to hearing and hearing-aids in adults. Hearing loss causes a multitude of negative emotions, while hearing aids generally reduce negative emotions and allow for more positive emotions. However, factors such as lifestyle, personality, situational control, the relationship with those in conversation and the attribution of blame are key to individual emotional experience. Clinical implications include the important role of social relationships in assessment and counselling.

An ethnography study exploring factors that influence social isolation in care home residents living with dementia and hearing loss

BACKGROUND

Hearing loss and dementia are highly prevalent conditions amongst older adults living in residential care. The consequences of living with these conditions may include social withdrawal and reduced communication opportunities. We sought to examine patterns of communication and interaction in residential care and explore resident, staff, and relative perspectives within two care homes located in Birmingham, UK. This enabled an understanding of how communication environments contributed to social isolation.

METHODS

This work used ethnography methodology to explore mechanisms that created and maintained social isolation in older adults living with dementia and hearing loss. A planning and engagement phase took place in four care homes. This was followed by an environmental audit, observations, and interviews. Data generated were analysed using Grounded Theory methods.

RESULTS

There were 33 participants (16 residents, 11 care staff, and six relatives) who took part in the observations and interviews. Residents experienced social isolation through lack of meaningful conversation with others and being misunderstood. Additionally, observations of residents' interactions informed the overall findings. A Grounded Theory model was employed to explain the core phenomenon of social isolation. The main contributors were internal and external barriers to communication, and reduced opportunities for meaningful conversation.

CONCLUSIONS

There is a wide range of social isolation that care home residents experience. This was not always associated with the severity of hearing loss but rather communication ability. Simple interventions such as staff dining with residents and focussing on improving communication could reduce social isolation within residential care settings.

Remote Technologies to Enhance Service Delivery for Adults: Clinical Research Perspectives

There are many examples of remote technologies that are clinically effective and provide numerous benefits to adults with hearing loss. Despite this, the uptake of remote technologies for hearing healthcare has been both low and slow until the onset of the COVID-19 pandemic, which has been a key driver for change globally. The time is now right to take advantage of the many benefits that remote technologies offer, through clinical, consumer, or hybrid services and channels. These include greater access and choice, better interactivity and engagement, and tailoring of technologies to individual needs, leading to clients who are better informed, enabled, and empowered to self-manage their hearing loss. This article provides an overview of the clinical research evidence-base across a range of remote technologies along the hearing health journey. This includes qualitative, as well as quantitative, methods to ensure the end-users' voice is at the core of the research, thereby promoting person-centered principles. Most of these remote technologies are available and some are already in use, albeit not widespread. Finally, whenever new technologies or processes are implemented into services, be they clinical, hybrid, or consumer, careful consideration needs to be given to the required behavior change of the key people (e.g., clients and service providers) to facilitate and optimize implementation.

Behavior Change in Chronic Health: Reviewing What We Know, What Is Happening, and What Is Next for Hearing Loss

Untreated age-related sensorineural hearing loss is challenged by low adoption and adherence to hearing aids for treatment. Hearing care has evolved from traditional clinic-controlled treatment to online consumer-centered hearing care, supported by the increasingly person-centered design of hearing aid technology. Greater evidence and a more nuanced understanding of the personal need for adoption versus adherence to the use of consumer hearing care devices are required. Research considering consumer hearing aid acceptance behavior rests on behavior modification theories to guide clinical approaches to increasing hearing aid adoption and adherence. However, in the context of complex chronic health management, there may be a gap in how these theories effectively align with the needs of consumers. Similarly, market data indicates evolving consumer behavior patterns have implications for hearing care theory and implementation, particularly in terms of sustained behavior change. This essay proposes that evidence, including theory and application, be strengthened by revising basic theoretical premises of personal experience with complex chronic health, in addition to considering recent changes in commercial contexts.

Providing information on mental well-being during audiological consultations: exploring barriers and facilitators using the COM-B model

OBJECTIVE

To identify the barriers and facilitators of hearing healthcare clinicians (HHC) providing information to audiology consumers on (i) the mental health impacts of hearing loss, and (ii) management options for improving mental well-being.

DESIGN

A qualitative study using semi-structured individual and group interviews. Both the interview guide and the deductive process of data analysis were based on the COM-B model (Capabilities, Opportunities and Motivations required for Behaviour change).

STUDY SAMPLE

Fifteen HHCs with between 2 and 25 years of clinical experience (mean 9.3).

RESULTS

Psychological Capability barriers included lack of knowledge relating to mental health signs and symptoms, management options available, referral processes, and resources/tools to assist discussion of options. Social opportunity barriers included clients' lack of openness to receive mental health-related information from their HHC. Automatic motivation factors included feeling uncomfortable and helpless when discussing mental health. Reflective motivation factors included clinician's limiting beliefs concerning their role and responsibilities regarding provision of mental health support, and doubts about whether mental health services are truly beneficial for clients with hearing loss.

CONCLUSION

Application of the COM-B model for behaviour change identified factors that need to be addressed to increase the provision of mental health information in the audiology setting.

Conversations about mental illness and health in adult audiological rehabilitation

OBJECTIVE

To understand the nature of mental health discussions in audiological rehabilitation, specifically, the types of conversations, when and how they are initiated, and the participant factors associated with discussing mental health.

DESIGN

A cross-sectional descriptive survey including quantitative (multiple choice) and qualitative (free-text) questions regarding mental health discussions between audiologists and clients.

STUDY SAMPLE

A convenience sample of 118 Australian audiologists working in adult audiological rehabilitation.

RESULTS

The majority of participants (95.8%) reported having engaged in discussions with clients about mental illness and health at some point throughout their career. The frequency of these discussions varied across participants: 7% rarely discuss, 50% discuss occasionally, 30% discuss with about half their clients and 13% have discussions with most clients. Many participants (85.6%) reported that clients would initiate these conversations, most often via disclosing the impacts of hearing loss on clients' lives.

CONCLUSIONS

Most audiologists will encounter clients with mental health concerns, and many will engage in conversations about psychological symptoms, therefore, training audiologists to recognise and address verbal and non-verbal cues regarding mental health may help to promote person-centred care and potentially improve outcomes.

Hearing aid Experiences of Adult Hearing aid Owners During and After Fitting: A Systematic Review of Qualitative Studies

There has been an increasing number of qualitative studies exploring the experiences and perceptions of adult hearing aid owners throughout their hearing aid journey. As these studies and reported experiences vary greatly, a systematic review was conducted to identify and synthesize the key concepts in adult hearing aid owners' experiences during and after fitting. A systematic search of three electronic databases was conducted, yielding 443 results. Articles were evaluated for inclusion based on pre-determined eligibility criteria, including conventional, smartphone-connected, and direct-to-consumer hearing devices. Twenty-five studies met the inclusion criteria. The quality of the included articles was evaluated using the Rating of Qualitative Research scale. Guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and the Synthesis Without Meta-Analysis (SWiM) were followed. A narrative synthesis was conducted, and studies were grouped into three main domains, namely experiences of owners related to a) hearing aid adoption and fitting (n = 3), b) hearing aid use (n = 20), and c) hearing aid sub-optimal use (n = 25). Hearing aid owners mainly reported on how their attitude towards hearing aids affected experiences during the fitting stage. Improved psychosocial functioning was the most prevalent perceived benefit of hearing aid use. Owners described sub-optimal use in terms of hearing device-related and non-device-related concepts. The COM-B (capability, opportunity, motivation-behavior) model is used to discuss specific service-delivery, hearing-device, and hearing-aid-owner related concepts and clinical implications, including behavior change techniques to enhance understanding of the concepts that hearing aid owners perceive as essential to improve hearing aid experiences.

Hearing disability and employment: a population-based analysis using the 2017 Canadian survey on disability

Purpose: The objectives of this study were to determine the effects of hearing disability on employment rates; examine how various factors are associated with employment; and identify workplace accommodations available to persons with hearing disabilities in Canada.Material and methods: A population-based analysis was done using the data collected through the 2017 Canadian Survey on Disability (CSD), representing 6 million (n = 6 246 640) Canadians. A subset of the complete dataset was created focusing on individuals with a hearing disability (n = 1 334 520). Weighted descriptive and multivariate logistic regression analyses were performed.Results: In 2017, the employment rates for working-age adults with a hearing disability were 55%. Excellent general health status (OR: 3.37; 95% CI: 2.29-4.96) and daily use of the internet (OR: 2.70; 95% CI: 1.78-4.10) had the highest positive effect on the employment rates. The top three needed but least available accommodations were communication aids (16%), technical aids (19%), and accessible parking/elevator (21%).Conclusion: Employment rates for persons with a hearing disability are lower than the general population in Canada. Employment outcomes are closely associated with one's general health and digital skills. Lack of certain workplace accommodations may disadvantage individuals with a hearing disability in their employment.Implications for RehabilitationPeople with severe hearing disabilities and those with additional disabilities may need additional and more rigorous services and supports to achieve competitive employment.It is important for the government to improve efforts toward inclusive education and develop strategies that promote digital literacy for job seekers with hearing disabilities.Officials concerned with implementing employment equity policies in Canada should focus on finding strategies that enable employees to have supportive conversations with their employers regarding disability disclosure and obtaining required accommodations.

Defining a Patient-Centred Core Outcome Domain Set for the Assessment of Hearing Rehabilitation With Clients and Professionals

Background

A variety of outcome domains are currently measured for the assessment of hearing rehabilitation. To date, there is no consensus about which outcome domains should be measured, when they should be measured, and how they should be measured. In addition, most studies seeking to develop core outcome sets and measures for hearing rehabilitation services have primarily focussed on the opinions and expertise of researchers, and, to a lesser extent, clinicians, rather than also involving clients of those services. The principles of experience-based co-design suggest that health services, researchers, and policymakers should come together with clients and their families to design health services and define what metrics should be used for their success.

Objectives

This study aimed to seek views and consensus from a range of key stakeholders to define which client-centred self-report outcome domains should be measured, when they should be measured, and how they should be measured, in a national publicly funded hearing rehabilitation scheme. In addition, the study aimed to identify current and future potential mechanisms and systems to standardise the collection of data and reporting of outcomes, to enable comparison across clients and hearing service providers.

Methods

Two stakeholder groups participated in a three-round online Delphi process: (1) 79 professional stakeholders involved in the delivery of hearing services in Australia, and (2) 64 hearing rehabilitation services’ clients identified by not-for-profit consumer organisations. An initial set of in-person workshops scoped the key issues upon which to develop the initial open-ended questions and subsequent Likert-scale statements addressing these issues. These statements were then distributed to both groups in an online survey. The respondent ratings were summarised, and the summary was returned to respondents along with a second round of the survey. This process was then repeated once more. The five most important outcome domains from both groups were then combined, and a consensus workshop of seven professionals and three client advocates agreed on the top four ranked domains.

Results

A range of potential outcome domains were identified as relevant indicators of successful hearing rehabilitation. Communication ability, personal relationships, wellbeing, and participation restrictions were identified as a core outcome domain set that should be measured as a minimum for patients receiving hearing rehabilitation. There was little agreement on the preferred timepoints for collection of outcome measures, with respondents expressing the view that this should be established by research once a set of outcome measures has been selected. However, there was broad agreement that measurements of these domains should be collected at baseline (before the provision of hearing rehabilitation) and no earlier than 3 months following the completion of rehabilitation. Potential benefits and issues with the development of a national outcomes database/collection system were also identified and prioritised, with participants highlighting the importance of valid, high-quality, trustworthy, and comprehensive data collection.

Conclusion

These results provide a Core Outcome Domain Set for the self-reported evaluation of hearing rehabilitation and provide important background information for the design of methods to implement them across hearing healthcare systems. However, the wide range of outcome domains identified as potentially providing important additional information and the lack of specific measures to address these domains strongly suggest that there is still more research to be done. Ongoing stakeholder engagement will continue to be vital for future implementation. In addition, further research is required to determine the optimal time following hearing rehabilitation to utilise any particular outcome measure.

Is There an Association Between Untreated Hearing Loss and Psychosocial Outcomes?

Objective

Age-related hearing loss is one of the leading causes of disability in older adults. This cross-sectional study investigated the association between untreated hearing loss, social (perception of quality and quantity of social network) and emotional loneliness (perception of limited emotional support), social isolation (size of the social network), social support (actual or perceived availability of resources from the social network) and psychological discomfort (depression, anxiety, and stress) in older adults.

Study Design

Cross-sectional study design.

Methods

A total of 202 community derived sample of volunteers, age range 40-89 years, mean age (M) = 65.3 ± 11.0 years were recruited. Of these 115 were females (M = 63.2 ± 12.0 years) and 87 were males (M = 68.2 ± 8.9 years). All participants completed a hearing assessment, social interaction and support questionnaire and a social and emotional loneliness questionnaire.

Results

Hearing loss significantly contributed to both moderate [P < 0.001, B (95% CI): 0.01 (0.99-1.02)] and intense levels [P < 0.001, 0.02 (1.00-1.04)] of emotional loneliness. Depression was significantly associated with satisfaction with social support [P < 0.001; -0.17 (-0.23 to -0.11), social interaction [P = 0.01; -0.07 (-0.12 to -0.01)], and moderate [P < 0.001; 0.31 (1.22-1.53)] and intense [P < 0.001; 0.29 (1.20-1.50)] levels of emotional loneliness and intense levels of social loneliness [P = 0.01; 0.12 (1.05-1.21)].

Conclusion

Untreated hearing loss significantly increases the odds of being emotionally lonely. Depression significantly contributes to social and emotional loneliness, satisfaction with social support and social loneliness. Given the higher prevalence of loneliness and psychological discomfort and their associations with untreated hearing loss, hearing-impaired older adults are at significant risk of developing loneliness and psychological discomfort. Therefore, hearing health professionals should be aware of the psychosocial burden that may accompany hearing loss, in order to provide appropriate advice and support.

Barriers and facilitators to asking adults with hearing loss about their emotional and psychological well-being: a COM-B analysis

OBJECTIVE

To explore the barriers and facilitators faced by hearing healthcare clinicians (HHCs) with respect to asking adults with hearing loss (HL) about their emotional well-being.

DESIGN

This qualitative study was conducted using semi-structured individual interviews and focus groups. The interview topic guide was developed based on the COM-B model.

STUDY SAMPLE

Fifteen HHCs of a single hearing services organisation in Western Australia across 13 clinic locations participated.

RESULTS

Barriers and facilitators that may influence HHCs' behaviour of routinely asking adults about their emotional well-being include having the knowledge and skills to ask about emotional well-being, forgetting to ask, awareness of the emotional impacts of HL, time and tools for asking, clients' reactions to being asked, supportive peers, normalisation of discussions relating to emotional well-being, presence of significant others, emotions associated with asking, being in the habit of asking, reminders, beliefs about consequences and confidence or capabilities, and scope of audiology practice.

CONCLUSIONS

Application of the COM-B model identified barriers in capabilities (e.g. knowledge), opportunities (e.g. tools), and motivation (e.g. beliefs about benefits of asking about emotions) that need to be addressed for HHCs to ask their clients about their emotional well-being.

Neural Activity during Story Listening Is Synchronized across Individuals Despite Acoustic Masking

Older people with hearing problems often experience difficulties understanding speech in the presence of background sound. As a result, they may disengage in social situations, which has been associated with negative psychosocial health outcomes. Measuring listening (dis)engagement during challenging listening situations has received little attention thus far. We recruit young, normal-hearing human adults (both sexes) and investigate how speech intelligibility and engagement during naturalistic story listening is affected by the level of acoustic masking (12-talker babble) at different signal-to-noise ratios (SNRs). In Experiment 1, we observed that word-report scores were above 80% for all but the lowest SNR (-3 dB SNR) we tested, at which performance dropped to 54%. In Experiment 2, we calculated intersubject correlation (ISC) using EEG data to identify dynamic spatial patterns of shared neural activity evoked by the stories. ISC has been used as a neural measure of participants' engagement with naturalistic materials. Our results show that ISC was stable across all but the lowest SNRs, despite reduced speech intelligibility. Comparing ISC and intelligibility demonstrated that word-report performance declined more strongly with decreasing SNR compared to ISC. Our measure of neural engagement suggests that individuals remain engaged in story listening despite missing words because of background noise. Our work provides a potentially fruitful approach to investigate listener engagement with naturalistic, spoken stories that may be used to investigate (dis)engagement in older adults with hearing impairment.

A qualitative study showing that a telecare tool can have benefits before and during the initial hearing assessment appointment

Objective: To examine patient and audiologist experiences and perspectives of using a patient-centred telecare tool, the Ida Institute's Why Improve My Hearing? (WIMH) Tool, before and during the initial hearing assessment appointment.Design: A qualitative study comprising individual semi-structured interviews using a maximum variation sampling strategy. The data were analysed using an established thematic analysis technique.Study sample: Fifteen participants, including ten patients (i.e. adults with hearing loss) and five audiologists, were recruited from Adult Audiology Services within the United Kingdom's publicly-funded National Health Service (NHS).Results: Three themes described the impact of using the WIMH Tool. Theme 1 (i.e. enhanced preparation before the appointment): the Tool helps patients to better understand and accept their hearing difficulties in advance of their first appointment. Theme 2 (i.e. enriched discussion during the appointment): the tool can enhance patient-centred communication, as well as the efficiency of the appointment. Theme 3 (i.e. varied impact on outcomes following the appointment): the Tool can improve patient motivation, readiness, and involvement in decision-making, though it may have limited impact on additional outcomes, such as adherence.Conclusion: The WIMH Tool can be successfully implemented in audiological practice, resulting in benefits before and during the initial hearing assessment appointment.

‘The worse my hearing got, the less sociable I got’: a qualitative study of patient and professional views of the management of social isolation and hearing loss

Background

Social isolation is a major consequence of hearing loss. It includes an objective component (e.g. small social network) and a subjective component (e.g. loneliness).

Objective

To examine the perspectives of key stakeholders regarding (i) the relationship between hearing loss and social isolation and (ii) interventions to address hearing loss and social isolation.

Design

A phenomenological qualitative study.

Setting

A UK research centre with a role to engage patients and clinicians.

Participants

Hearing healthcare professionals (n = 7) and adults with hearing loss (n = 6) were recruited via maximum variation sampling.

Methods

Individual (n = 3) and group (n = 3) semi-structured interviews were conducted. Inductive thematic analysis was performed.

Results

Five themes were identified. Theme 1 (experience of isolation and hearing loss): hearing loss can cause people to feel disconnected at social events or to cease attending them. Theme 2 (complexity of isolation and hearing loss): the various causes of isolation (e.g. hearing loss, retirement, comorbidities) are difficult to disentangle. Theme 3 (downstream effects of isolation and hearing loss): hearing loss and/or isolation can lead to mental health problems, stigmatisation, fatigue and unemployment. Theme 4 (preferred components of an isolation intervention): an isolation intervention should be patient-led and patient-centred and take place in the community. Theme 5 (challenges to implementing an isolation intervention): barriers to implementing an isolation intervention include a lack of time, training and continuity.

Conclusion

This study demonstrated that social isolation arising from hearing loss is a substantial, complex problem and provided novel insights on implementing an intervention to address this issue.

Addressing Emotional and Psychological Problems Associated With Hearing Loss: Perspective of Consumer and Community Representatives

PURPOSE

Hearing loss causes emotional distress and can contribute to the development of psychological difficulties, yet emotional and psychological issues are not addressed within current audiology services. The purpose of this study was to use focus groups with consumer and community representatives to explore how we might improve the provision of support for clients experiencing emotional and psychological issues in relation to their hearing loss.

PARTICIPANTS

Adults with hearing loss (n = 19) and their significant others (n = 9), as well as 10 hearing health care professionals (n = 4 hearing health care clinicians, n = 4 reception staff, and n = 2 clinical managers), participated in consumer and community engagement focus groups.

METHOD

Consumer and community representatives were tasked with (a) identifying the stakeholders involved in supporting adults experiencing emotional or psychological difficulties on account of their hearing loss, (b) describing the behaviors undertaken by each stakeholder group, and (c) selecting target behavior(s) that could optimally form the basis of an intervention program to improve the quality and frequency of support provided to people experiencing emotional and psychological problems in the audiology setting.

RESULTS

Participants identified 12 stakeholder groups involved in supporting adults with hearing loss experiencing emotional and psychological problems. The three behaviors voted by participants to be the most promising for a behavioral intervention included the clinician (a) asking about, (b) providing information on, and (c) delivering therapeutic intervention for emotional and psychological well-being within audiological service provision.

CONCLUSION

Consumer and community stakeholder representatives indicate a general desire for hearing health care clinicians to deliver support for the emotional and psychological issues that arise relating to hearing loss.

Perspectives on Mental Health Screening in the Audiology Setting: A Focus Group Study Involving Clinical and Nonclinical Staff

PURPOSE

Audiology clinical guidelines recommend the use of mental health screening tools; however, they remain underutilized in clinical practice. As such, psychological concerns are frequently undetected in adults with hearing loss. This study aimed to better understand audiology clinic staff's perspectives (including audiologists, audiometrists, reception staff, and clinic managers) on how to improve detection of poor mental health by (a) exploring the role of audiology clinic staff in detecting psychological concerns in adults with hearing loss and (b) investigating the appropriateness, acceptability, and usability of several screening tools in an audiology setting.

METHOD

Eleven audiology clinic staff (M _age = 33.9 ± 7.3, range: 25-51 years) participated in a semistructured focus group. First, participants discussed the role of audiology clinic staff in detecting psychological difficulties in adults with hearing loss, including current practices and needs for improving practices. Second, participants discussed the appropriateness, acceptability, and usability of nine standardized mental health screening tools commonly used in wider health care settings.

RESULTS

Audiology clinic staff described their role in being aware of, and detecting, psychological difficulties, as well as their part in promoting an understanding of the link between hearing loss and mental health. Participants described the need to provide support following detection, and highlighted barriers to fulfilling these roles. The use of mental health screening tools was considered to be client and context specific. The language used within the screener was identified as an important factor for its acceptability by audiology clinic staff.

CONCLUSIONS

Audiology clinic staff acknowledged that they have an important role to play in the detection of psychological difficulties and identified the core barriers to using screening tools. Future research may explore the possibility of developing a mental health screening tool specific to the unique experiences of adults with comorbid hearing loss and mental health concerns.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.16702501.

Illegal Drug Use and Risk of Hearing Loss in the United States: A National Health and Nutrition Examination Survey

The use of illegal drugs may be a risk factor of hearing loss. However, very few studies with large sample size have investigated the relationship between illegal drug use and hearing loss. Therefore, to evaluate the association between illegal drug use and hearing loss, this cross-sectional population-based study collected data from the US National Health and Nutrition Examination Survey 2011. The study included 1772 participants aged 20 to 59 years who underwent the Drug Use Questionnaire and Audiometry Examination. Of the 1772 participants in this study, 865 were men (48.8%) and 497 were illegal drug users. The mean (SD) age of the patients was 40.0 (11.4) years. After considering age, sex, and comorbidities, the participants who used illegal drugs were found to have higher risks of high-frequency hearing loss (adjusted odds ratio (OR), 1.69; 95% confidence interval (CI), 1.35–2.10) and overall hearing loss (adjusted OR, 1.69; 95% CI, 1.36–2.12) as compared with the nonusers. In the second analysis, the participants who used ≥ 2 types of illegal drugs were associated with higher risks of high-frequency hearing loss (adjusted OR, 1.57; 95% CI, 1.06–2.32) and overall hearing loss (adjusted OR, 1.60; 95% CI, 1.08–2.37). In the third analysis, cocaine use was associated with increased risks of high-frequency hearing loss (adjusted OR, 1.34; 95% CI, 1.01–1.77) and overall hearing loss (adjusted OR, 1.38; 95% CI, 1.04–1.82). The adjusted OR for overall hearing loss in the methamphetamine users was 1.54 (95% CI, 1.05–2.27) as compared with that in the nonusers. This study shows that illegal drug users might have a higher risk of overall hearing loss than nonusers. In addition, the analysis results demonstrated that the more kinds of illegal drugs used, the higher the risk of hearing loss. Further experimental and longitudinal research studies are required to confirm the causal relationship between illegal drug use and hearing loss.

Hearing Aids Reduce Daily-Life Fatigue and Increase Social Activity: A Longitudinal Study

People with hearing loss experience fatigue, and it is unknown whether this is alleviated by treatment with hearing aids. The objective of this study was to address this issue and to investigate the possible concomitant effect of hearing-aid fitting on activity levels. An intervention group (n = 53) who were due to be fitted with their first-ever hearing aid(s) and a control group (n = 53) who had hearing loss but no change in hearing aid status-completed a battery of self-report outcome measures four times: once before fitting, and at 2 weeks, 3 months, and 6 months post fitting. Self-report outcome measures at each assessment captured fatigue, listening effort, hearing handicap, auditory lifestyle, social participation restrictions, and work, social and physical activity levels. Hearing-aid fitting led to a significant reduction in listening-related fatigue, but not general fatigue, in the intervention group compared to the control group. Additionally, social activity level increased and social participation restriction decreased significantly after hearing aid fitting in the intervention group compared to the control group. No significant interaction was found between working status and change in listening-related fatigue score. This study is the first to make a longitudinal measurement of fatigue before and after first-ever hearing aid fitting and to identify an increase in social activity level after hearing aid fitting. These findings have important implications for future research and the clinical practice of hearing aid fitting.

The Effect of Social Media Use on Depressive Symptoms in Older Adults with Self-Reported Hearing Impairment: An Empirical Study

Older people with hearing impairment are more likely to develop depressive symptoms due to physical disability and loss of social communication. This study investigated the effects of social media on social relations, subjective aging, and depressive symptoms in these older adults based on the stimulus-organism-response (S-O-R) framework. It provides new empirical evidence to support improving the mental health and rebuilding the social relations of older people. A formal questionnaire was designed using the Wenjuanxing platform and distributed online through WeChat; 643 valid questionnaires were received from older people with self-reported hearing impairments, and SmartPLS 3.28 was used to analyze the data. The results show that (1) social media significantly impacts the social relations of older people with hearing impairment (social networks, β = 0.132, T = 3.444; social support, β = 0.129, T = 2.95; social isolation, β = 0.107, T = 2.505). (2) For these older people, social isolation has the biggest impact on their psychosocial loss (β = 0.456, T = 10.458), followed by the impact of social support (β = 0.103, T = 2.014); a hypothesis about social network size was not confirmed (β = 0.007, T = 0.182). Both social media (β = 0.096, T = 2.249) and social support (β = 0.174, T = 4.434) significantly affect the self-efficacy of hearing-impaired older people. (3) Both subjective aging (psychosocial loss, β = 0.260, T = 6.036; self-efficacy, β = 0.106, T = 3.15) and social isolation (β = 0.268, T = 6.307) significantly affect depressive symptoms in older people with hearing impairment. This study expands the theories of social media aging cognition, social support, and social networks and can provide practical contributions to the social media use and mental health of special persons 60 years and older.

"Something is just not right with my hearing": early experiences of adults living with hearing loss

OBJECTIVE

To understand the psychosocial process of how adults experience hearing loss; specifically, their readiness to accept that they may have hearing loss, and the challenges and coping strategies associated with it.

DESIGN

A grounded theory methodology guided the research. A patient-orientated research approach informed the study. Thirty-nine individual interviews and six focus groups were completed.

STUDY SAMPLE

Participants included 68 individuals aged 50 years and older with self-reported hearing loss living in Newfoundland and Labrador.

RESULTS

The theoretical construct, 'Realising that something is just not quite right with my hearing' captured individuals' experiences as they gradually awakened to the fact that they had hearing loss. Three categories describe the process: (1) Rationalising suspicions, (2) Managing the invisible and (3) Reaching a turning point.

CONCLUSIONS

Many individuals do not recognise hearing loss in its early stages, although they may be already experiencing its negative effects. It is important to identify motivators to engage individuals as early as possible in their hearing health. Taking a proactive approach to hearing health can help mitigate the potential negative outcomes of hearing loss.

Cogmed Training Does Not Generalize to Real-World Benefits for Adult Hearing Aid Users: Results of a Blinded, Active-Controlled Randomized Trial

Objectives:

Performance on working memory tasks is positively associated with speech-in-noise perception performance, particularly where auditory inputs are degraded. It is suggested that interventions designed to improve working memory capacity may improve domain-general working memory performance for people with hearing loss, to benefit their real-world listening. We examined whether a 5-week training program that primarily targets the storage component of working memory (Cogmed RM, adaptive) could improve cognition, speech-in-noise perception and self-reported hearing in a randomized controlled trial of adult hearing aid users with mild to moderate hearing loss, compared with an active control (Cogmed RM, nonadaptive) group of adults from the same population.

Design:

A preregistered randomized controlled trial of 57 adult hearing aid users (n = 27 experimental, n = 30 active control), recruited from a dedicated database of research volunteers, examined on-task learning and generalized improvements in measures of trained and untrained cognition, untrained speech-in-noise perception and self-reported hearing abilities, pre- to post-training. Participants and the outcome assessor were both blinded to intervention allocation. Retention of training-related improvements was examined at a 6-month follow-up assessment.

Results:

Per-protocol analyses showed improvements in trained tasks (Cogmed Index Improvement) that transferred to improvements in a trained working memory task tested outside of the training software (Backward Digit Span) and a small improvement in self-reported hearing ability (Glasgow Hearing Aid Benefit Profile, Initial Disability subscale). Both of these improvements were maintained 6-month post-training. There was no transfer of learning shown to untrained measures of cognition (working memory or attention), speech-in-noise perception, or self-reported hearing in everyday life. An assessment of individual differences showed that participants with better baseline working memory performance achieved greater learning on the trained tasks. Post-training performance for untrained outcomes was largely predicted by individuals’ pretraining performance on those measures.

Conclusions:

Despite significant on-task learning, generalized improvements of working memory training in this trial were limited to (a) improvements for a trained working memory task tested outside of the training software and (b) a small improvement in self-reported hearing ability for those in the experimental group, compared with active controls. We found no evidence to suggest that training which primarily targets storage aspects of working memory can result in domain-general improvements that benefit everyday communication for adult hearing aid users. These findings are consistent with a significant body of evidence showing that Cogmed training only improves performance for tasks that resemble Cogmed training. Future research should focus on the benefits of interventions that enhance cognition in the context in which it is employed within everyday communication, such as training that targets dynamic aspects of cognitive control important for successful speech-in-noise perception.

Exploring Current Practice, Knowledge, and Training Needs for Managing Psychosocial Concerns in the Audiology Setting: Perspectives of Audiologists, Audiology Reception Staff, and Managers

Purpose The purpose of this study was to explore the current practices and training requirements for supporting clients experiencing psychosocial concerns in the audiology setting, from the perspectives of audiology clinicians, managers, and reception staff. Method Convenience sampling was used to recruit audiologists, reception staff, and clinic managers (N = 13, M _age = 32.2 ± 8.1, range: 25-47 years, 11 female) through a large hearing services provider in Western Australia. A semistructured focus group was used to elicit participant views regarding current experiences relating to clients who express psychosocial concerns in the audiology setting, familiarity with psychosocial interventions, and training requirements for delivery of psychosocial interventions in the audiological setting. Results Twenty-four subthemes were identified across six themes: (1) awareness of psychosocial well-being, (2) the role of others, (3) identifying client's psychosocial needs, (4) managing client's psychosocial needs, (5) barriers to providing psychosocial support, and (6) broadening audiological services to include psychosocial support. Conclusions Participants reported an awareness of their clients' psychosocial challenges within the audiology setting, yet they described uncertainty in how best to respond in providing support and whether this was within their scope of practice. A majority of audiology staff expressed desire and motivation to broaden the scope of their service in order to better address their clients' hearing loss-related psychosocial needs.

Operationalization of the Brief ICF Core Set for Hearing Loss: An ICF-Based e-Intake Tool in Clinical Otology and Audiology Practice

OBJECTIVES

According to the International Classification of Functioning, Disability and Health (ICF), functioning reflects the interplay between an individual's body structures and functions, activities, participation, environmental, and personal factors. To be useful in clinical practice, these concepts need to be operationalized into a practical and integral instrument. The Brief ICF Core Set for Hearing Loss (CSHL) provides a minimum standard for the assessment of functioning in adults with hearing loss. The objective of the present study was to operationalize the Brief CSHL into a digital intake tool that could be used in the otology-audiology practice for adults with ear and hearing problems as part of their intake assessment.

DESIGN

A three-step approach was followed: (1) Selecting and formulating questionnaire items and response formats, using the 27 categories of the Brief CSHL as a basis. Additional categories were selected based on relevant literature and clinical expertise. Items were selected from existing, commonly used disease-specific questionnaires, generic questionnaires, or the WHO's official descriptions of ICF categories. The response format was based on the existing item's response categories or on the ICF qualifiers. (2) Carrying out an expert survey and a pilot study (using the three-step test interview. Relevant stakeholders and patients were asked to comment on the relevance, comprehensiveness, and comprehensibility of the items. Results were discussed in the project group, and items were modified based on consensus. (3) Integration of the intake tool into a computer-based system for use in clinical routine.

RESULTS

The Brief CSHL was operationalized into 62 items, clustered into six domains: (1) general information, including reason for visit, sociodemographic, and medical background; (2) general body functions; (3) ear and hearing structures and functions; (4) activities and participation (A&P); (5) environmental factors (EF); and (6) personal factors (mastery and coping). Based on stakeholders' responses, the instructions of the items on A&P and EF were adapted. The three-step test interview showed that the tool had sufficient content validity but that some items on EF were redundant. Overall, the stakeholders and patients indicated that the intake tool was relevant and had a logical and clear structure. The tool was integrated in an online portal.

CONCLUSIONS

In the current study, an ICF-based e-intake tool was developed that aims to screen self-reported functioning problems in adults with an ear/hearing problem. The relevance, comprehensiveness, and comprehensibility of the originally proposed item list was supported, although the stakeholder and patient feedback resulted into some changes of the tool on item-level. Ultimately, the functioning information obtained with the tool could be used to promote patient-centered ear and hearing care taking a biopsychosocial perspective into account.

How Can eHealth Meet the Hearing and Communication Needs of Adults With Hearing Impairment and their Significant Others? A Group Concept Mapping Study

OBJECTIVES

To seek the perspectives of key stakeholders regarding: (1) how eHealth could help meet the hearing and communication needs of adults with hearing impairment and their significant others; and (2) how helpful each aspect of eHealth would be to key stakeholders personally.

DESIGN

Group concept mapping, a mixed-methods participatory research method, was used to seek the perspectives of key stakeholders: adults with hearing impairment (n = 39), significant others (n = 28), and hearing care professionals (n = 56). All participants completed a short online survey before completing one or more of the following activities: brainstorming, sorting, and rating. Brainstorming required participants to generate ideas in response to the focus prompt, "One way I would like to use information and communication technologies to address the hearing and communication needs of adults with hearing loss and their family and friends is to…." The sorting task required participants to sort all statements into groups that made sense to them. Finally, the rating task required participants to rate each of the statements according to "How helpful would this idea be to you?" using a 5-point Likert scale. Hierarchical cluster analysis was applied to the "sorting" data to develop a cluster map using the Concept Systems software. The "rating" data were subsequently analyzed at a cluster level and an individual-item level using descriptive statistics. Differences in cluster ratings between stakeholder groups were examined using Kruskal-Wallis tests.

RESULTS

Overall, 123 statements were generated by participants in response to the focus prompt and were included in subsequent analyses. Based on the "sorting" data and hierarchical cluster analysis, a seven-cluster map was deemed to be the best representation of the data. Three key themes emerged from the data, including using eHealth to (1) Educate and Involve Others; (2) Support Aural Rehabilitation; and (3) Educate About and Demonstrate the Impacts of Hearing Impairment and Benefits of Hearing Rehabilitation. Overall median rating scores for each cluster ranged from 3.97 (educate and involve significant others) to 3.44 (empower adults with hearing impairment to manage their hearing impairment from home).

CONCLUSIONS

These research findings demonstrate the broad range of clinical applications of eHealth that have the capacity to support the implementation of patient- and family-centered hearing care, with self-directed educational tools and resources typically being rated as most helpful. Therefore, eHealth appears to be a viable option for enabling a more biopsychosocial approach to hearing healthcare and educating and involving significant others in the hearing rehabilitation process without adding more pressure on clinical time. More research is needed to inform the subsequent development of eHealth interventions, and it is recommended that health behavior change theory be adhered to for such interventions.

Coping with the social challenges and emotional distress associated with hearing loss: a qualitative investigation using Leventhal's self-regulation theory

OBJECTIVE

To explore the lived experience of social challenges and emotional distress in relation to hearing loss and the coping mechanisms employed to manage them.

DESIGN

Two focus groups and two one-on-one semi-structured interviews were conducted during February 2020. Transcripts were first inductively analysed to identify experiential categories of social and emotional difficulty, and then deductively analysed using Leventhal's self-regulation model to identify how individuals conceptualised these experiences and the coping mechanisms employed to manage them.

STUDY SAMPLE

Adults with hearing loss and self-reported emotional distress due to their hearing loss (n = 21) and their significant others (n = 9).

RESULTS

Participants described their social and emotional experiences of hearing loss in terms of negative consequences (social overwhelm, fatigue, loss, exclusion), identity impact (how they perceive themselves and are perceived by others), and emotional distress (frustration, grief, anxiety, loneliness, and burdensomeness). While many participants described a general lack of effective coping strategies, others described employing coping strategies including avoidance (helpful and unhelpful), controlling the listening environment, humour, acceptance, assertiveness, communication repair strategies, and accepting support from significant others.

CONCLUSION

Many participants described a lack of effective coping strategies and tended to rely on avoidance of social interaction,deepening their isolation and loneliness.

Understanding patient empowerment along the hearing health journey

OBJECTIVE

Related to the hearing health journey, this study aimed to: (i) explore how empowerment manifests itself from individuals' first awareness of hearing loss through to hearing aid fitting and then to becoming an active hearing aid user, (ii) identify points when the different dimensions of empowerment are most relevant, and (iii) conceptualise empowerment.

DESIGN

A semi-structured interview study was conducted, followed by a template analysis of the data.

STUDY SAMPLE

Adult hearing aid users from Sweden (n = 8) and Australia (n = 10) who had worn hearing aids for between 6 and 36 months.

RESULTS

The themes that emerged from the transcripts were knowledge, skills and strategies, participation, self-efficacy, and control.

CONCLUSIONS

This study conceptualises empowerment along the hearing health journey as the process through which individuals with hearing-related challenges acquire and use knowledge, skills, and strategies, and increase self-efficacy, participation, and the feeling of control of their hearing health care, hearing solutions, and everyday lives. There are not specific points along the hearing health journey where any dimension is uniquely relevant, instead, each dimension is a dynamic component at all stages.

Arts activity and well-being for visually impaired military veterans: a narrative discussion of current knowledge

OBJECTIVES

The objective of this study was to offer an overview of literature relating to the topic of arts as activity within the context of military and veteran health and to consider the implications of current knowledge on future research with visually impaired veterans.

STUDY DESIGN

A search for literature addressing the topic of visual art activities with visually impaired veterans was undertaken. No research addressing this topic was identified. A review of literature on the related topics of mental health and well-being in military veterans, visual impairment and mental health and well-being, and art therapy for veteran populations was carried out to offer an overview of current knowledge.

RESULTS

While there is growing evidence of the benefits of arts engagement among both general and military populations, the role of the visual arts in the everyday lives of broader veteran samples, and the impact of these activities on holistic well-being, remains underexplored. The current article highlights the need for art as activity to be differentiated from art as therapy and argues that the former might offer a tool to positively impact the holistic well-being of visually impaired veterans.

CONCLUSIONS

Future research relating to the use of visual art activities in the context of veteran health and well-being should endeavour to explore the potential impacts of engagement on holistic well-being. Research is needed to build on anecdotal evidence of the positive impact of arts engagement on visually impaired veterans by systematically exploring if, and how, holistic well-being in this population may be impacted by engagement with visual art activities.

Community first response and out-of-hospital cardiac arrest: a qualitative study of the views and experiences of international experts

OBJECTIVES

This research aimed to examine the perspectives, experiences and practices of international experts in community first response: an intervention that entails the mobilisation of volunteers by the emergency medical services to respond to prehospital medical emergencies, particularly cardiac arrests, in their locality.

DESIGN

This was a qualitative study in which semistructured interviews were conducted via teleconferencing. The data were analysed in accordance with an established thematic analysis procedure.

SETTING

There were participants from 11 countries: UK, USA, Canada, Australia, New Zealand, Singapore, Ireland, Norway, Sweden, Denmark and the Netherlands.

PARTICIPANTS

Sixteen individuals who held academic, clinical or managerial roles in the field of community first response were recruited. Maximum variation sampling targeted individuals who varied in terms of gender, occupation and country of employment. There were eight men and eight women. They included ambulance service chief executives, community first response programme managers and cardiac arrest registry managers.

RESULTS

The findings provided insights on motivating and supporting community first response volunteers, as well as the impact of this intervention. First, volunteers can be motivated by 'bottom-up factors', particularly their characteristics or past experiences, as well as 'top-down factors', including culture and legislation. Second, providing ongoing support, especially feedback and psychological services, is considered important for maintaining volunteer well-being and engagement. Third, community first response can have a beneficial impact that extends not only to patients but also to their family, their community and to the volunteers themselves.

CONCLUSIONS

The findings can inform the future development of community first response programmes, especially in terms of volunteer recruitment, training and support. The results also have implications for future research by highlighting that this intervention has important outcomes, beyond response times and patient survival, which should be measured, including the benefits for families, communities and volunteers.

Health Status of Adults with Hearing Loss in the United States

Purpose: The purpose of this study was to identify the current health status of adults in the United States with self-reported hearing loss and compare it with US adults with a self-reported excellent or good hearing in three areas: (1) chronic disease states and general health status, (2) medical screening behaviors, and (3) lifestyle behaviors. Methods: A secondary data analysis was conducted using the 2014 data set from the National Health Interview Survey (NHIS), specifically the Sample Adult Public Use File (samadult). For this questionnaire set, one adult per family was randomly selected. This individual self-reported their response to the questionnaire items. Binary regressions were used to analyze the odds ratio to find differences for selected disease states, screenings, and lifestyle behaviors. Respondents were grouped into one of four categories: excellent/good hearing, a little trouble hearing, moderate/a lot of trouble hearing, and deaf. Results: The excellent/good hearing group was used as the comparison group for the other three levels of hearing. There are many differences in likelihood to self-report disease states; the greatest increased likelihoods include tinnitus and heart disease, with tinnitus being 8.6 times more likely for those who identified as having moderate/a lot of hearing loss. Those with any level of hearing loss were 3 to 5 times more likely to self-report heart disease. Regarding lifestyle factors, individuals with any level of hearing loss were less likely to consume alcohol and 2.5 to 9 times more likely to be unable to engage in moderate or vigorous activity on a weekly basis, respectively. Conclusions: There is a difference in the health status of individuals with hearing loss across all three areas examined (chronic disease states and general health status, medical screening behaviors, and lifestyle behaviors), and those differences vary based on level of hearing loss, the most notable being the self-reported inability to engage in moderate and vigorous physical activity. Disproportionate rates of tinnitus and heart disease were evident in all levels of hearing loss but most notable in those identifying as having moderate/a lot of trouble hearing. Further interdisciplinary research is necessary to improve the health of individuals with all levels of hearing loss, increase awareness of the hearing/health connection, and decrease hearing loss in general.

Reconnecting to others: grounded theory of social functioning following age-related hearing loss

Age-related hearing loss (ARHL) is common and a known risk factor for social disengagement in later life. This study explored social functioning following a diagnosis of ARHL. Using a constructivist grounded theory approach we developed an interview schedule to advance a grounded theory from data collected from six older adults who used either hearing aids or cochlear implants. Interview questions concerned social functioning as well as focusing on their perspective of the impact of ARHL on cognitive functioning. We describe a grounded theory conceived as ‘Reconnecting to Others’. This theory posits that participants faced social challenges in relation to their ARHL, and resolved these challenges partly through the use of hearing aids and cochlear implantation. The theory also emphasises the importance of help from other hearing aid users for new users, and corroborates prior findings about strategies older adults with ARHL use to cope with their hearing impairment in various social situations. Once hearing aids and cochlear implants are used and adapted to with the help of peers, participants completed their journey by helping others who had received diagnoses of ARHL. Additionally, participants spoke of the pleasure of hearing again. Interestingly, no participant felt that their ARHL had impacted their cognitive functioning. Our theory provides a basis for explaining existing quantitative findings as well as creating new hypotheses for future testing.

Covid-19 Lockdown Affects Hearing Disability and Handicap in Diverse Ways: A Rapid Online Survey Study

OBJECTIVES

The aim of this study was to explore the perceived effects of coronavirus disease 2019 (Covid-19) social distancing restrictions and safety measures on people with hearing loss.

DESIGN

Participants were 129 adults (48.1% female, mean age 64.4 years) with an audiometric hearing loss, living in Glasgow, Scotland. A rapidly deployed 24-item online questionnaire asked about the effects of certain aspects of lockdown, including face masks, social distancing, and video calling, on participants' behavior, emotions, hearing performance, practical issues, and tinnitus. Data were analyzed descriptively across the entire sample, and with Chi-squared tests for differences between subgroups self-reporting relatively good and relatively poor unaided hearing, respectively. Additional free-text responses provided further perspectives.

RESULTS

Behavior: Video calls are used more frequently than prelockdown. The better-hearing group use their hearing aids less. Emotions: There is increased anxiety (especially among the worse hearing group) concerning verbal communication situations and access to audiology services, and greater rumination about one's own hearing loss. Enjoyment of group video calls is mixed. The worse hearing group shows substantial relief at not being obliged to attend challenging social gatherings. Across both groups, a majority would like to see all key workers equipped with transparent face masks. Hearing performance: A large majority finds it hard to converse with people in face masks due to muffled sound and lack of speechreading cues, but conversing at a safe distance is not universally problematic. In the worse hearing group, performance in video calls is generally inferior to face-to-face, but similar to telephone calls. Those who use live subtitling in video calls appreciate their value. TV and radio updates about Covid-19 are easy to follow for most respondents. There is only weak evidence of face mask fixtures interfering with hearing aids on the ear, and of tinnitus having worsened during lockdown.

CONCLUSIONS

With due regard for the limitations of this rapid study, we find that there are many negative-and a few positive-effects of Covid-19 restrictions and safety measures on people with hearing loss. From a societal perspective, the widespread adoption of clear face masks may alleviate some of the difficulties and anxieties this population experience. From an individual perspective, one may consider using live subtitles on video calls. Manufacturers of hearing devices should consider developing processing modes and accessories specifically designed for video calls. Finally, repair and maintenance services should be resumed as soon as it is safe to do so.

Can listening-related fatigue influence well-being? Examining associations between hearing loss, fatigue, activity levels and well-being

Objective

Well-being is influenced by the activities we undertake. Hearing loss may reduce well-being directly through increased listening-related fatigue due to cognitive and emotional strain in challenging situations. Hearing loss and hearing device use may also indirectly impact fatigue and well-being by altering the frequency and type of daily-life activities. This review examines the available literature to help understand the relationships.

Design

We provide (i) a summary of the extant literature regarding hearing loss, hearing device use and fatigue in adults, as well as regarding fatigue and daily-life activity (work, social and physical) and (ii) a systematic search and narrative review of the relationships between hearing loss, hearing device use and activity.

Study sample

The systematic search resulted in 66 eligible texts.

Results

Data examining well-being in persons with hearing loss are limited. Our literature review suggests that well-being can be related directly and indirectly to hearing loss, hearing device use, activity level and listening-related fatigue.

Conclusions

Variations and interactions between hearing loss, hearing device use, fatigue and activity levels can be expected to impact well-being in persons with hearing loss in direct and indirect ways. Future research linking hearing and daily-life fatigue should take account of activity levels.

Social Representation of "Hearing Loss" Among People with Hearing Loss: An Exploratory Cross-Cultural Study

BACKGROUND

Hearing loss can have an effect on the physical, psychosocial, and cognitive wellbeing of an individual. Despite the research on attitudes and stigma associated with hearing loss, people with hearing loss (PHL) continue to delay seeking help. Thus, it is vital to look at alternative theories which have been successfully used in disability research to better understand how PHL perceive hearing loss.

PURPOSE

The aim of the current exploratory study was to examine the social representation (SR) of "hearing loss" in PHL in India, Republic of Korea (ROK), United Kingdom (UK), and the United States (US).

RESEARCH DESIGN

The study used a cross-sectional survey design.

STUDY SAMPLE

In this study, 424 participants were recruited using a consecutive sampling method in four countries (India, Republic of Korea, United Kingdom, and United States).

DATA COLLECTION AND ANALYSIS

Data collection was conducted using a questionnaire. Data were analyzed using content analysis, similarities analysis, prototypical analysis, and chi-square analysis.

RESULTS

The free associations of the PHL were grouped into 37 categories. The most commonly reported categories were communication difficulties, negative mental state, aging, assessment and management, causes of hearing loss, hearing ability or disability, hearing instruments, and symptoms of hearing loss. Similarities analysis and prototypical analysis highlighted two main negative categories (negative mental state and communication difficulties) which form the central elements of SR of hearing loss. PHL associated hearing loss mainly as a negative phenomenon, but with some positive and neutral aspects. Respondents from ROK reported a greater number of neutral associations compared with other countries. There were cross-cultural similarities and differences in terms of PHL's SR of hearing loss, but there were more similarities than differences.

CONCLUSION

The study provides an insight into how PHL collectively view their "hearing loss" and helps to develop our understanding of the influence of culture on the SR of "hearing loss." The results will aid the development of culturally appropriate public education campaigns, marketing material, and appropriate rehabilitation for PHL.