The fitting of amplification and the provision of hearing aid orientation are often the beginning and end of the aural rehabilitation (AR) process.1-5 There is, however, growing evidence that additional AR services result in better outcomes.6-10
Unfortunately, results of a 1990 survey indicated that fewer clinicians were providing communication training, including speechreading and auditory training, than in 1980, down from 38% to 23%.11 A follow-up survey by Millington in 2000 (as cited in Schow and Nerbonne12) suggested little change in the provision of communication training since 1990.
The reduction in the delivery of communication training may not reflect a lessening of overall services, but rather a shift away from the traditional components of AR to services that address informational and psychosocial aspects of hearing loss. A review of recent literature revealed that many AR program models do include these topics.5,6,8,13–23 The purpose of the current survey was to determine which of the AR services described and recommended in the literature are being provided to adults by clinical audiologists.
Eight AR services other than hearing aid fitting and orientation identified in the literature were: (1) information on assistive listening devices (ALDs), (2) auditory training, (3) communication strategy training, (4) coping strategy training, (5) frequent communication partner training, (6) information/educational counseling, (7) psychosocial adjustment counseling, and (8) speechreading training. These were identified by consulting the American Speech-Language-Hearing Association (ASHA) scope of practice24 and by reviewing textbooks4,13–18 and other literature in the area.5,8,19-23 The eight services are defined in Table 1.
The questionnaire included these definitions and elicited information from the respondents on which services they provide, how often, in what format, and using what media. Respondents also rated the benefit of each service, the adequacy of their preparation to provide AR, and the feasibility of, and their interest in, including these services in their practice. In addition, the survey included questions covering the following areas: demographics, education and experience, work setting, and hours.
The survey recipients were selected from the membership directory of the American Academy of Audiology (AAA). This membership directory was selected because it includes information regarding dispensing status and work setting. All dispensing audiologists on the list were identified by the following work settings: hospital, private practice, ENT/MD office, speech and hearing clinic, university, or Veterans Administration/military. The list was periodically sampled (every ninth name) until 50 names from each of the six work settings were selected.
Dissemination and response rate
Of the 300 survey questionnaires mailed*, 120 (40%) were returned by the deadline and 110 (37%) were usable. Four surveys were excluded because the respondents did not treat adults and six could not be used because the audiologists were not currently practicing. We entered the data into SPSS (version10.0) for statistical analysis.
While equal numbers of questionnaires were sent to each of the six work settings, the return rate varied from 10% from speech and hearing clinics to 64% from ENT/MD offices. Response rates from the other four settings were relatively similar (29%-40%).
Most of the respondents were female (71%), held master's degrees (80%), had more than 16 years of experience (61%), and worked full time (82%). Males were more likely to have PhDs (44% versus 10% of the women), work full time (97% versus 76%), have more than 20 years' experience (75% versus 24%), and work in a university or military setting (55% versus 23%). Men were somewhat overrepresented in this survey at 29% compared to the 20% reported by both ASHA25 and AAA.26 This overrepresentation of males may account for the overrepresentation of PhDs (20% versus 15% in the AAA 2000 survey) and full-time employees (82% versus 78% in the ASHA 2001 report).
No statistically significant differences were noted between male and female respondents on questions related to AR service provision. Results for provision of services across all work settings are depicted in Figure 1.
Three fairly distinct clusters of services emerged from the responses from all work settings: frequently provided, sometimes provided, and rarely provided services. Respondents reported delivering the same three AR services most frequently: information on ALDs (84%), communication strategies training (83%), and information/education counseling (82%). For each work setting, these three services were the most frequently provided as well (71% to 100%).
With rare exceptions (military/VA not providing coping strategies training and universities providing auditory and speechreading training more often than frequent communication partner training), the rank order of the other services provided in each work setting was similar to that of the group as a whole: Coping strategies training (provided by 57% of all respondents), psychosocial adjustment counseling (45%), and frequent communication partner training (38%) were the services fourth, fifth, and sixth most often provided by respondents in each work setting, while auditory training ranked seventh and speechreading training eighth in each setting (see Figure 2). While the pattern from most to least frequently provided service was similar for MA/MS and PhD respondents, the latter were more likely to provide coping strategies training, frequent communication partner training, auditory training, and speechreading training.
The format of service delivery was informal (i.e., discussion of issues and topics as they arise and providing information as needed) 66% of the time. Only 5% of respondents said they provided group AR while 16% reported having both individual and group sessions. Of those who reported providing individual AR sessions (67%), all but one offered them informally. Most of those surveyed (82%) indicated that they offered handouts to their clients; fewer offered videotapes (30%) and books (20%).
Respondents were also asked to rate the perceived benefit of each of the eight identified components. Not surprisingly, the pattern was similar to that of service provision: the services rated as most beneficial were those provided most often, while those rated as least beneficial were provided least often. However, for each of the eight services, the percentage of respondents rating it as beneficial exceeded the percentage that said they provided that service most of the time. For example, 100% of the respondents rated providing information on ALDs as beneficial, while 78% said they provided that service most of the time (See Figure 3).
Barriers to service provision
More than 70% of all respondents reported that they had the knowledge and training to provide AR services and the pattern was similar for all work settings except hospitals, where 64% of the responses were neutral for knowledge and 43% were neutral about training. Nearly half (48%) of all respondents and over 70% of hospital and private-practice respondents indicated lack of time as a barrier to more service delivery.
Lack of resources was reported to be less of a barrier (23%) overall, but there was wide variation among settings, from VA/military indicating this was not a barrier at all to hospitals and private practices indicating it was less a barrier than lack of time, but still an issue (35%–40%).
Lack of interest in providing services was not a factor for nearly two-thirds of the respondents. However, the greatest difference among work settings was found in this area: None of the clinic, university, or VA/military respondents reported lack of interest as a reason for not providing a service, while most (85%) hospital respondents did. All private-practice respondents were neutral on this issue.
DISCUSSION AND CONCLUSIONS
The findings of this survey clearly demonstrate that the traditional AR components of speechreading and auditory training have fallen out of favor with dispensing audiologists. This is probably due to a number of factors, including the recognition that their efficacy with most adults is equivocal at best4,27,28 and the incompatibility of the formal nature and time demands of the provision of these services with the informal service delivery model adopted by most practitioners.
The most frequently provided components (information/educational counseling, communication strategies training, and information about ALDs) are more easily accommodated in an informal, as-needed format. They also all involve providing information, an activity that practitioners may find more comfortable than the more emotionally laden areas of coping strategies training and psychosocial adjustment counseling. Logistics may also be one reason that frequent communication partner training is not provided more frequently. Another difficulty may be convincing the communication partner(s) that there is a need to change their behavior when they are not “the one with the problem.”
A noteworthy finding was the relative lack of interest among hospital-based personnel in providing more services. One possible explanation seemed to be that audiologists employed in hospitals do more diagnostic work and less dispensing. However, that was not the case among the respondents. The proportion of their practice that was devoted to dispensing amplification placed hospital audiologists squarely in the middle relative to the other settings. Another possible explanation is that services that are therapy-like are deemed less appropriate in a hospital setting.
PhD audiologists reported delivering more services than did practitioners with a master's degree. This may be because most of the PhDs work in settings where compensation for services is less an issue (VA/military and university). Or it may reflect the additional courses or clinical work in AR service provision at the doctoral level. If the latter is true, we may anticipate a reversal of the trend toward fewer AR services as more audiologists earn AuD degrees.
Although all the respondents in this survey reported feeling prepared to provide AR services, most also reported that it would be beneficial if they provided more such services. Perhaps continuing/ongoing education will result in more familiarity with the literature supporting the value of these services, which may in turn motivate practitioners to find ways to deliver them efficiently.
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