Obtaining the patient's perspective on communication problems by means of questionnaires, interviews, and scales has been an area of interest to audiologists for many years.1-7 Because communication involves partners as well as patients, a few instruments have been designed to obtain the perspective of significant others (SOs) as well. Currently, audiologists have available the following tools specifically designed as significant other (SO) scales:
- The Hearing Handicap Inventory for the Elderly for use with Spouses (HHIE-SP)8 measures the spouse's judgment as an indicator of the outcome of rehabilitative intervention;
- The Significant Other Assessment of Communication (SOAC),9 the companion scale to Schow and Nerbonne's Self Assessment of Communication,9 screens for primary communication difficulties and for secondary emotional and social consequences.
- The McCarthy-Alpiner Scale (M-A Scale)10 assesses the effects of hearing loss on the patient, while a companion version assesses these effects on family members.
The HHIE-SP, SOAC, and M-A Scale give the audiologist a great deal of useful information. But, because they are not designed as pre- and post-fitting measures, they have not been used to determine the effects of SO involvement on any aspect of aural rehabilitation. Another instrument, the Abbreviated Profile of Hearing Aid Benefit (APHAB),11 was specifically designed to obtain pre/post measures on one component of aural rehabilitation—patients' perceived hearing aid benefit. However, it has not been described as an SO instrument.
The purpose of this study was to determine if the APHAB would reveal any differences in perception of hearing aid benefit when the SO was included in initial discussions on hearing aid candidacy.
Forty subjects (mean age = 61 years; range 23–100 years) with acquired sensorineural hearing impairment (HI subjects) were selected from a group of new patients seen at the first author's private practice. These patients indicated that they could include a significant other (spouse, sibling, other family member, close friend) in their office visits. This SO was a person reported to be well acquainted with the lifestyle and activities of the HI subject.
No HI subject's hearing loss was poorer than moderately severe as determined by routine hearing evaluation procedures. HI subjects and their SOs were informed orally and in writing that their participation was strictly voluntary.
After providing written consent to participate in this study, HI subjects with their SOs were randomly assigned to either a control group (Group A) or an experimental group (Group B). Group A consisted of 20 HI subjects (7 males, 13 females) with an average age of 76.2 years (range 43 to 90). The average age of their SOs was 61.6 years (range 35 to 91).
Group B consisted of 20 HI subjects (10 males, 10 females) with an average age of 72.5 years (range 35 to 100). The average age of their SOs was 53.15 years (range 20 to 85).
Group A completed the APHAB as originally designed: That is, each HI subject independently completed the instrument before the hearing aid fitting. During this time, the SO remained in the reception area.
Approximately 1 month later, each HI subject and SO in Group A returned for a post-fitting hearing aid check. During that session, both the HI subject and the SO independently completed the APHAB and then discussed the results with the audiologist.
Group B completed the APHAB using an alternate method. At the initial session, both the HI subject and the SO independently completed this instrument and then discussed the results with the audiologist before the hearing aid fitting. Approximately 1 month later, the HI subject and SO returned for a post-fitting hearing aid check. During that session, the HI subject and SO again independently completed the APHAB and again discussed the results with the audiologist.
Scores were recorded with a hearing aid manufacturer's software program. The APHAB was completed within an average of 15 minutes.
The APHAB was used to measure changes in perceived hearing aid benefit. The APHAB, developed by Cox and Alexander,11 is a version of the Profile of Hearing Aid Performance (PHAP)12 and a shortened version of the Profile of Hearing Aid Benefit (PHAB).13 It is used frequently because of its brief completion time and high internal reliability.14
The APHAB contains 24 statements, each assigned to one of four subscales: Ease of Communication, Reverberation, Background Noise, and Aversiveness of Sounds. Each statement describes a particular listening situation; patients are asked to rate the frequency of the time that the statement is true by selecting one of seven responses. These responses range from “always” (99%) to “never” (1%).
Analyses were conducted with the “total benefit” scores in the APHAB categories. Total benefit scores were obtained according to APHAB instructions: That is, unaided percentages minus aided percentages equal total benefit percentages for each category.
Because the responses from the APHAB were ordinal data, we obtained median (and range of) responses for each group. We performed the Mann-Whitney U test to measure the differences in benefit scores between the HI subject in Groups A and Group B across each APHAB category. The criterion adopted for statistical significance was p <0.05.
APHAB scores were collected from 40 HI subjects and their SOs between May and August 2000. Analyses of the total benefit scores are reported below for each group by category.
Pre-hearing aid fitting
The following pre-hearing aid fitting APHAB scores were obtained (see Table 1):
Ease of Communication: Median score for Group A was 33% (range 14%-74%); median score for Group B was 52% (range 22%–85%).
Reverberation: Median score for Group A was 50% (range 25%–93%); median score for Group B was 56% (range 25%-81%).
Background Noise: Median score for Group A was 54% (range 25%–93%); median score for Group B was 57% (range 25%-87%).
Aversiveness of Sounds: Median score for Group A was 2% (range 1%–25%); median score for Group B was 2% (range 1%–18%).
Because self-perceptions are by definition subjective measures, it was anticipated that a group of randomly assigned subjects would report a wide range of perceptions with regard to the impact of hearing loss on their lives.15 Indeed, a Mann Whitney U test of median scores showed no significant differences between groups in any category, indicating that, although each group reported a wide range in scores, the two groups were similar in their “average” report of hearing problems before their hearing aid fittings.
Post-hearing aid fitting
Ease of Communication: The median score of Group A was 27% (range 2%-54%) and the median score of Group B was 38% (range 12%-73%). The Mann-Whitney U test indicated statistically significant differences between Group A and B HI subjects (p <0.05). These findings suggest that when SOs were involved in the pre-fitting stage, the HI subjects perceived greater ease in communication than did the control group.
Reverberation: The median score of Group A was 38% (range 23%-71%), and the median score of Group B was 42.5% (range 17%-67%). The Mann-Whitney U test indicated no statistical significance between Groups A and B.
Background Noise: The median score of Group A was 36.5% (range 23%-68%), and the median score of Group B was 43.5% (range 23%-69%). The Mann-Whitney U test indicated statistical significance at the 0.10 level of probability, not within acceptable criteria for this study but worthy of note.
Aversiveness of Sounds: The median score of Group A was -10% (range of -23% to 15%) and the median score of Group B HI was -5% (range of -24% to 8%). (Note: Percentage scores in this category are reported in negative numbers. This could result from the fact that a side effect of wearing any hearing instrument is that loud sounds are louder, so the patient could perceive these changes as negative in the first several months of use.) The Mann-Whitney U test indicated statistically significant differences between Groups A and B (p <0.05). This finding suggests that when SOs were involved in the pre-fitting stage, the HI subjects perceived a less deleterious effect from environmental noises in this category. See Table 1 for a summary of pre- and post-fitting APHAB scores for both groups.
The purpose of this study was to determine if SO involvement in the initial hearing aid fitting session would affect patients' perceived hearing aid benefit. Analyses of the data indicated statistically significant differences between groups in post-hearing aid fitting scores in the Ease of Communication and the Aversiveness of Sounds categories. That is, when SOs were involved in pre-hearing aid fitting discussions, patients later reported more hearing aid benefit in these two categories. It is possible that, because of the pre-fitting review of these categories, SOs were able to recognize changes in communication ease and the presence of aversive listening conditions, and because they were included in the adjustment process from the beginning, they discussed the effects of these conditions with the patient during the trial period.
No statistical differences were found between HI subjects in Group A and Group B for the Reverberation and Background Noise categories. In spite of the pre-fitting discussion on these variables, reverberation may not be a variable to which an SO would be sensitive. However, it would be expected that SOs could identify and notice the effects of background noise; future studies with larger numbers of subjects may be able to address this issue.
Future research is also recommended to determine if an “SO effect” is influenced by other factors, such as age or gender of subjects, experience in hearing aid use, hearing aid circuit, length of trial period, and type of significant other (daughter versus spouse, for example).
Additional investigation is needed to examine the effect on the nature of the interaction between patient and SO as a result of the pre-fitting discussion of the patient's hearing problems. That is, did the pre-fitting discussion facilitate the adjustment process?
Finally, because of the interactive process of hearing aid counseling, it is not known if the responses of subjects or significant others were influenced by the fact that the audiologist (first author) was not blind to the research project. Future research is recommended to examine this variable.
This study had some limitations. Only digital hearing aids were used for hearing aid fittings. Possibly a less sophisticated circuit would have yielded different responses from subjects and their SOs. Also, post-fitting observations were recorded after a 30-day trial period. Results might have been different had responses been measured after a longer time.
This study quantifies, possibly for the first time, a positive influence on patients' perceived hearing aid benefit as a result of SO involvement in the adjustment process. In this study, the SOs in Group B participated in a directed discussion about patients' hearing problems prior to the hearing aid fitting, while the SOs in Group A did not. Since the HI subjects in Group B reported significantly greater perceived patient benefit in two of the four categories of the APHAB, it would appear that SO involvement during the initial stages of the hearing aid fitting had a positive effect on hearing aid adjustment.
There is still a great deal to learn about the possible effects of including a significant other in the pre-fitting stage of the process. However, this introductory study does suggest that the early involvement of the SO could have a positive influence on a possibly difficult process.