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Social Connectedness and Perceived Listening Effort in Adult Cochlear Implant Users

A Grounded Theory to Establish Content Validity for a New Patient-Reported Outcome Measure

Hughes, Sarah E.1,2; Hutchings, Hayley A.2; Rapport, Frances L.3; McMahon, Catherine M.4,5; Boisvert, Isabelle4,5

doi: 10.1097/AUD.0000000000000553
Research Articles

Objectives: Individuals with hearing loss often report a need for increased effort when listening, particularly in challenging acoustic environments. Despite audiologists’ recognition of the impact of listening effort on individuals’ quality of life, there are currently no standardized clinical measures of listening effort, including patient-reported outcome measures (PROMs). To generate items and content for a new PROM, this qualitative study explored the perceptions, understanding, and experiences of listening effort in adults with severe-profound sensorineural hearing loss before and after cochlear implantation.

Design: Three focus groups (1 to 3) were conducted. Purposive sampling was used to recruit 17 participants from a cochlear implant (CI) center in the United Kingdom. The participants included adults (n = 15, mean age = 64.1 years, range 42 to 84 years) with acquired severe-profound sensorineural hearing loss who satisfied the UK’s national candidacy criteria for cochlear implantation and their normal-hearing significant others (n = 2). Participants were CI candidates who used hearing aids (HAs) and were awaiting CI surgery or CI recipients who used a unilateral CI or a CI and contralateral HA (CI + HA). Data from a pilot focus group conducted with 2 CI recipients were included in the analysis. The data, verbatim transcripts of the focus group proceedings, were analyzed qualitatively using constructivist grounded theory (GT) methodology.

Results: A GT of listening effort in cochlear implantation was developed from participants’ accounts. The participants provided rich, nuanced descriptions of the complex and multidimensional nature of their listening effort. Interpreting and integrating these descriptions through GT methodology, listening effort was described as the mental energy required to attend to and process the auditory signal, as well as the effort required to adapt to, and compensate for, a hearing loss. Analyses also suggested that listening effort for most participants was motivated by a need to maintain a sense of social connectedness (i.e., the subjective awareness of being in touch with one’s social world). Before implantation, low social connectedness in the presence of high listening effort encouraged self-alienating behaviors and resulted in social isolation with adverse effects for participant’s well-being and quality of life. A CI moderated but did not remove the requirement for listening effort. Listening effort, in combination with the improved auditory signal supplied by the CI, enabled most participants to listen and communicate more effectively. These participants reported a restored sense of social connectedness and an acceptance of the continued need for listening effort.

Conclusions: Social connectedness, effort-reward balance, and listening effort as a multidimensional phenomenon were the core constructs identified as important to participants’ experiences and understanding of listening effort. The study’s findings suggest: (1) perceived listening effort is related to social and psychological factors and (2) these factors may influence how individuals with hearing loss report on the actual cognitive processing demands of listening. These findings provide evidence in support of the Framework for Understanding Effortful Listening a heuristic that describes listening effort as a function of both motivation and demands on cognitive capacity. This GT will inform item development and establish the content validity for a new PROM for measuring listening effort.

1South Wales Cochlear Implant Programme, Bridgend, United Kingdom

2Swansea University Medical School, Swansea University, Swansea, United Kingdom

3The Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia

4Department of Linguistics (Audiology Section), Macquarie University, Sydney, New South Wales, Australia

5The HEARing Cooperative Research Centre, Melbourne, Victoria, Australia.

Received September 29, 2016; accepted December 6, 2017.

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Portions of this article were presented at the British Society of Audiology Annual Conference, Coventry, United Kingdom, April 25–27, 2016; the British Cochlear Implant Group Academic Meeting, London, United Kingdom, April 28–29, 2016; and at the Listening Effort Workshop, Australian Hearing Hub, Macquarie University, Sydney, Australia, February 26, 2016.

The authors have no conflicts of interest to disclose.

Address for correspondence: Sarah E. Hughes, South Wales Cochlear Implant Programme, Princess of Wales Hospital, Coity Road, Bridgend, Wales CF31 1RQ, United Kingdom. E-mail:

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