|Year : 2015 | Volume
| Issue : 2 | Page : 124-128
Survey on hearing aid use and satisfaction in patients with presbyacusis
Nalini Bhat, Shalaka S Shewale, Pushkar D Kasat, Harshada S Tawade
Department of ENT, BARC Hospital, Anushakti Nagar, Mumbai, Maharashtra, India
|Date of Web Publication||20-Apr-2015|
Dr. Nalini Bhat
Department of ENT, BARC Hospital, Anushakti Nagar, Mumbai - 400 094, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: Hearing aids (HAs) are the principal means of auditory rehabilitation for patients with sensorineural hearing loss. Yet, there are a lot of resistances to use HAs due to the expense, cosmetic concerns and lack of sufficient perceived benefit. A scientific analysis of outcomes in HAs users and the factors involved will lead to a better understanding among the care givers and will ultimately positively influence the outcomes in the HA users. This is the basis of the following study. Aims: (1) To assess the subjective level of satisfaction in patients of presbycusis using mono-aural HAs. (2) To study various attributes in HA users. Settings and Design: Study design - Prospective. Study period - February 2011 to September 2012. Subjects and Methods: The study was done in five basic steps: (1) Selection of subjects based on inclusion criteria. (2) Awareness and counseling regarding HAs. (3) Preintervention assessment. (4) HA fitting, adjustment and rehabilitation. (5) Postintervention assessment. Statistical Analysis Used: Mean, percentage, two-tailed P value using Fischer exact. Results: There was a high level of satisfaction in terms of hearing benefit (74%) among users at the end of 4 months. Almost half the subjects reported no problems with their HAs. Subjects with mild hearing impairment were less satisfied with their HAs than the others. Most people under used their HAs even when they were satisfied. Subjects with severe hearing loss used their HAs for longer duration daily. Conclusions: Mono-aural HAs significantly and satisfactorily rehabilitate patients with presbycusis. Mono-aural fitting is a cost effective option, especially in developing countries like ours.
Keywords: Hearing aids, Presbycusis, Satisfaction
|How to cite this article:|
Bhat N, Shewale SS, Kasat PD, Tawade HS. Survey on hearing aid use and satisfaction in patients with presbyacusis. Indian J Otol 2015;21:124-8
| Introduction|| |
According to the World Health Organization, by 2025 there will be approximately 1.2 billion people in the world over the age of 60, which marks a shift in world population to a greater proportion of older people. Age-related hearing loss is a leading cause of years lived with disability in the adult years. 
Hearing aids (HAs) are the principal means of auditory rehabilitation for patients with presbycusis. Yet, there is a lot of resistances to use HAs due to the expense, cosmetic concerns and lack of sufficient perceived benefit.
A scientific analysis of outcomes in HAs users and the factors involved will lead to a better understanding among the care givers and will ultimately positively influence the outcomes in the HA users.
| Subjects and Methods|| |
The subjects were recruited from the ENT Department at BARC Hospital, which caters to a closed population of approximately 85,000. It was a prospective study, conducted on an outpatient basis from February 2011 to September 2012. Participants were enrolled in the study based on the following inclusion criteria:
- Adults with sensorineural hearing loss (SNHL) equal to or worse than 30 dB in their better ear (averaged over 500, 1000, 2000 and 4000 Hz)
- Symmetrical SNHL with interaural difference within 30 dB at all octave and half-octave intervals from 250 to 4000 Hz
- Absence of middle ear pathology (normal tympanogram) and air-bone gap of <10 dB at all frequencies in both ears
- No known fluctuating or rapidly progressing hearing loss
- Willing to use HA and be a part of the study
- No previous HA use
- Capable of responding to questionnaire-verbal/written.
The study was done in five basic steps.
Selection of subjects based on inclusion criteria
All patients, being seen for a HA trial, were briefed about the study and the eligibility criteria. Participants who expressed interest and met the inclusion criteria were enrolled in the study.
Awareness and counseling regarding hearing aids
The participants were counseled about how a HA works, its use and realistic expectations were set.
Preintervention assessment with Client Oriented Scale of Improvement and Hearing Handicap Inventory for the Elderly-Screening Version
Brief description of questionnaires
Hearing Handicap Inventory for the Elderly-Screening Version
contains 10 items and subjects are asked to rate their hearing handicap under specific listening conditions. The Hearing Handicap Inventory for the Elderly-Screening Version (HHIE-S) score represented the subject's own perception of his/her hearing loss as no handicap, mild-moderate handicap and severe handicap. Lower scores indicate lower self-perceived hearing handicap. 
Client Oriented Scale of Improvement
This measures the need fulfillment of the individual using HA. Subjects were asked to list five listening situations in everyday life where they would like improvement, in order of importance. At end of 4 months the subjects were asked to report their final ability (with HA) in the listed hearing situations as "hardly ever" (10%), "occasionally" (25%), "half the time," (50%) "most of the time" (75%), "almost always" (95%). 
Hearing aid fitting, adjustment and rehabilitation
The subjects were provided mono-aural HAs free of cost (up to a ceiling amount) under the Central Government Health Scheme. All the subjects were given an option of binaural HA, provided they paid for the second HA. However, none of them opted for the same. Similarly, subjects could opt for a more expensive HA provided they pay the difference in the amount above the ceiling limit. Shell-style was chosen according to gain requirements and cosmetic preferences. Totally, 61 subjects were fitted with behind-the-ear models, and seven were fitted with an in-the-canal model. They were programmed with the manufacturer's fitting software.
Postintervention assessment was done at the end of 4 months based on:
Client Oriented Scale of Improvement
The level of satisfaction in hearing ability was determined as per Client Oriented Scale of Improvement (COSI) scores. Subjects who reported hearing ability of 75% or more were considered satisfied.
Subjective measure of hours of daily use
Subjects were asked to respond if they almost never used their aids, used <8 h or used their aids at least 8 h daily.
Problems with instrument use or service provider
Subjects were asked to report any problems that they had in using their aids regarding positioning, manipulating controls, feedback/whistling, ear mould/shell discomfort, ambient noise discomfort, poor quality of one's own voice and service provided.
| Results|| |
Totally, 68 subjects were completed the study, ranging from 51 to 79 years of age. Mean age of the study group was 65.88 years.
Males far outnumbered the females with a male: female ratio of 53:15.
Comparing severity of hearing loss on pure-tone audiometry and subjective handicap
The severity of hearing loss was graded based on the pure tone average (averaged across 0.5, 1k, 2k and 4kHz) [Figure 1]. The degree of perceived handicap was assessed using the HHIE-S scores [Figure 2]. A comparison between the two revealed that the degree of hearing loss co-related with the handicap perceived by the subjects in 68% of the cases. Here data for moderate and moderately severe hearing loss groups, on pure-tone audiometry, were collapsed into a single moderate group (average hearing loss <60 dB) and scores above 24 were clubbed into severe handicap to compare with HHIE S scores.
|Figure 1: Severity of hearing loss on pure-tone audiometry (averaged across 0.5, 1k, 2k and 4 kHz)|
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|Figure 2: Degree of handicap on Hearing Handicap Inventory for the Elderly-Screening Version|
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- Client Oriented Scale of Improvement scores - Subjects were considered to be satisfied with their HA, if they reported their final ability in the specific listening situations as "most of the times" (75%) or "almost always" (95%)
- There was a significantly high level of satisfaction (74%) in terms of hearing benefit among users at the end of 4 months [Figure 3]. Two-tailed P < 0.0001 - Fischer exact)
- Hours of daily use - Most (n = 45,) subjects (66%) used their HA for <8 h, while 18 (26.5%) used them for <8 h and 5 (7.5%) subjects used HA for less than an hour
- Problems encountered - 48% subjects reported no problems with their HAs. Ambient noise discomfort (14%) and difficulty in using aid with telephone (13%), were the most commonly reported problems, the others being, ear mould discomfort (8%), battery life (6%), feedback (8%), manipulating controls (2%), positioning (1%) and poor quality of own voice. Hearing care professionals received excellent ratings-nearly perfect.
Comparing degree of hearing loss and satisfaction level
Subjects with mild hearing impairment were found to be less satisfied with their HAs as compared to the others [Figure 4].
|Figure 4: Comparison between degree of hearing loss and satisfaction levels|
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Comparing satisfaction level and hours of use
Most subjects used their HA for <8 h. There was a tendency to underuse the HA, even when they were satisfied with the HA [Figure 5].
Comparing degree of hearing loss and hours of use
Subjects with severe SNHL were found to use their HA more often than others [Figure 6].
| Discussion|| |
The inevitable deterioration in hearing ability that occurs with age-presbycusis is associated with significant psychosocial effects. Remediation of presbycusis is an important contributor to quality of life. The projected global rise in proportion of the geriatric population has made it necessary to assess the efficacy of the HA dispensing system. In the present study, outcomes were measured based on subjective levels of hearing satisfaction, hours of daily use and possible confounding factors in use of HAs.
The degree to which a given hearing loss affects an individual's life is related to his lifestyle, occupation, academic concerns, psychological factors, etc. Hence, the hearing loss on audiogram may not always correspond to the degree of handicap experienced by the patient. In our study, the degree of hearing loss co-related with the handicap perceived by the subjects on HHIE-S in 68% of the cases. Sensitivity of HHIE-S, when compared to audiogram defined hearing impairment, has been reported as 72-76% and specificity 71-77% (cut off score of 8)  The HHIE-S has been found to be sufficiently sensitive and specific to provide reasonable estimates of hearing loss prevalence and is recommended for use in epidemiological studies and as a basis for referral for further evaluation. 
Traditionally, HA benefit has been assessed by objective tests that compare aided and unaided speech reception thresholds and speech recognition ability. However, a discrepancy is often noted between the HA benefit, in terms of speech understanding and self-experienced outcome. This is because, objective tests are done with a predefined external standard and are almost exclusively done in a laboratory. Laboratory conditions often fail to simulate real-world listening situations. Furthermore, each individual comes with different expectations from the HA fitting. Self-report measures address the unique needs of all individuals and have become the new "gold-standard" for measuring and reporting success.  According to cox, self-report outcome measures are increasing in use because they give us a scientifically defensible way to validly measure the real-life success of the HA fitting. 
We used COSI to assess the level of improvement in hearing because it is an open-ended problems questionnaire, which can address the unique needs of all individuals. 74% of the subjects were satisfied with their HAs in terms of hearing benefit. Most studies have found HAs to be beneficial. Kochkin  and Bertoli et al.,  have reported satisfaction levels of up to 80% in studies involving large samples.
The benefits of binaural amplification have been considered in a number of studies. They include improved speech in noise discrimination and localization of sounds in the horizontal plane, loudness summation, tinnitus suppression and a psychological feeling of being in a 3-dimensional auditory world.  However, Walden and Walden have reported that bilateral amplification is not always beneficial in everyday listening environment  Many other studies have similarly reported that some subjects fitted with binaural HAs use only one aid at a time in some listening situations or always. These subjects would probably have benefitted with one HA, as well. ,,
Considering the high cost of HAs and that people with economic limitations for acquiring them dominate our practice, mono-aural HAs seem like a viable option for patients with presbycusis.
In the present study, subjects with mild hearing impairment were found to be less satisfied with their HAs as compared to the others. This could be because of lesser degree of perceived handicap and hence the lack of sufficient perceived benefit. Bertoli et al., have reported that the degree of handicap had no influence on satisfaction rates. 
Most subjects used their HA for <8 h. There was a tendency to under use the HA, even when they were satisfied with the HA. Surr et al., have similarly reported that a majority of the population used their aids selectively rather than on a full-time basis. Excessive background noise and lack of need constituted 63% of the reasons given for limited use or nonuse.  Contrastingly, Bertoli et al., have reported that 85% of the studied group used their HAs regularly. 
Subjects with severe SNHL were found to use their HA more often than others, possibly due to the greater degree of handicap. Bertoli et al., too have found that the strongest determinant to regular use was severity of hearing loss. 
Our study revealed that background noise (14%) and difficulty in use with telephone (13%) were the most common confounding factors in the use of HAs. Köjbler et al., have also reported that 16% of their subjects reported background noise as troublesome and 14% reported ear mould discomfort.  Disturbing background noise and wearing discomfort have been reported as the most common cause of nonuse by Bertoli et al. 
Finally our study revealed that HA are used predominantly by males, an observation endorsed by Kochkin who has found that 6 out of 10 HA users were male though the percentage of female users has increased by 3% as compared to earlier studies. 
Though, these observations seem to be clinically significant, the sample size was too small to claim a statistically significant difference.
To conclude, mono-aural HAs are a cost-effective means of rehabilitation of patients with presbycusis, especially in developing countries like ours. They are recommended as the initial means of rehabilitation for patients with age-related hearing loss, especially of a mild to moderately severe degree. Binaural fitting may be tried in subjects, who do not adequately benefit with mono-aural HA fitting or directly, in those with a severe degree of hearing loss. The HHIE-S can be effectively used as a screening tool for referral for further evaluation by the primary health care providers. Finally, technological advances in HA models in terms of reducing background noise and improving use along with telephone are recommended.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]