Implementing Ecological Momentary Assessment in Audiological Research: Opportunities and Challenges.

Ecological momentary assessment (EMA) is a way to evaluate experiences in everyday life. It is a powerful research tool but can be complex and challenging for beginners. Application of EMA in audiological research brings with it opportunities and challenges that differ from other research disciplines. This tutorial discusses important considerations when conducting EMA studies in hearing care. While more research is needed to develop specific guidelines for the various potential applications of EMA in hearing research, we hope this article can alert hearing researchers new to EMA to pitfalls when using EMA and help strengthen their study design. The current article elaborates study design details, such as choice of participants, representativeness of the study period for participants' lives, and balancing participant burden with data requirements. Mobile devices and sensors to collect objective data on the acoustic situation are reviewed alongside different possibilities for EMA setups ranging from online questionnaires paired with a timer to proprietary apps that also have access to parameters of a hearing device. In addition to considerations for survey design, a list of questionnaire items from previous studies is provided. For each item, an example and a list of references are given. EMA typically provides data sets that are rich but also challenging in that they are noisy, and there is often unequal amount of data between participants. After recommendations on how to check the data for compliance, reactivity, and careless responses, methods for statistical analysis on the individual level and on the group level are discussed including special methods for direct comparison of hearing device programs.

Test-retest reliability of the urban outdoor situated phoneme (SiP) test.

OBJECTIVE: To introduce the urban outdoor version of the Situated Phoneme (SiP) test and investigate its test-retest reliability. DESIGN: Phonemic discrimination scores in matched-spectrum real-world (MSRW) maskers from an urban outdoor environment were measured using a three-alternative forced choice test paradigm at different phoneme-to-noise ratios (PNR). Each measurement was repeated twice. Test-retest scores for the full 84-trial SiP-test, as well as for four types of contrasting phonemes, were analysed and compared to critical difference scores based on binomial confidence intervals. STUDY SAMPLE: Seventy-two adult native speakers of Swedish (26-83 years) with symmetric hearing threshold levels ranging from normal hearing to severe sensorineural hearing loss. RESULTS: Test-retest scores did not differ significantly for the whole test, or for the subtests analysed. A lower amount of test-retest score difference than expected exceeded the bounds of the corresponding critical difference intervals. CONCLUSIONS: The urban outdoor SiP-test has high test-retest reliability. This information can help audiologists to interpret test scores attained with the urban outdoor SiP-test.

Focusing on positive listening experiences improves hearing aid outcomes in experienced hearing aid users.

OBJECTIVE: The purpose of this study was to investigate whether focusing on positive listening experiences improves hearing aid outcomes in experienced hearing aid users. DESIGN: The participants were randomised into a control or positive focus (PF) group. At the first laboratory visit, the Client-Oriented Scale of Improvement (COSI) questionnaire was administered followed by hearing aid fitting. The participants wore the hearing aids for three weeks. The PF group was asked to report their positive listening experiences via an app. During the third week, all the participants answered questionnaires related to hearing aid benefit and satisfaction. This was followed by the second laboratory visit where the COSI follow-up questionnaire was administered. STUDY SAMPLE: Ten participants were included in the control and eleven in the PF group. RESULTS: Hearing aid outcome ratings were significantly better in the PF group in comparison to the control group. Further, COSI degree of change and the number of positive reports were positively correlated. CONCLUSIONS: These results point to the importance of asking hearing aid users to focus on positive listening experiences and talk about them. The potential outcome is increased hearing aid benefit and satisfaction which could lead to more consistent use of the devices.

Bayesian analysis of Ecological Momentary Assessment (EMA) data collected in adults before and after hearing rehabilitation.

This paper presents a new Bayesian method for analyzing Ecological Momentary Assessment (EMA) data and applies this method in a re-analysis of data from a previous EMA study. The analysis method has been implemented as a freely available Python package EmaCalc, RRID:SCR 022943. The analysis model can use EMA input data including nominal categories in one or more situation dimensions, and ordinal ratings of several perceptual attributes. The analysis uses a variant of ordinal regression to estimate the statistical relation between these variables. The Bayesian method has no requirements related to the number of participants or the number of assessments by each participant. Instead, the method automatically includes measures of the statistical credibility of all analysis results, for the given amount of data. For the previously collected EMA data, the analysis results demonstrate how the new tool can handle heavily skewed, scarce, and clustered data that were collected on ordinal scales, and present results on interval scales. The new method revealed results for the population mean that were similar to those obtained in the previous analysis by an advanced regression model. The Bayesian approach automatically estimated the inter-individual variability in the population, based on the study sample, and could show some statistically credible intervention results also for an unseen random individual in the population. Such results may be interesting, for example, if the EMA methodology is used by a hearing-aid manufacturer in a study to predict the success of a new signal-processing method among future potential customers.

Conversation success in one-to-one and group conversation: a group concept mapping study of adults with normal and impaired hearing.

OBJECTIVE: The concept of conversation success is undefined, although prior work has variously related it to accurate exchange of information, alignment between interlocutors, and good management of misunderstandings. This study aimed (1) to identify factors of conversation success and (2) to explore the importance of these factors in one-to-one versus group conversations. DESIGN: Group concept mapping method was applied. Participants responded to two brainstorming prompts ("What does 'successful conversation' look like?" and "Think about a successful conversation you have taken part in. What aspects of that conversation contributed to its success?"). The resulting statements were sorted into related clusters and rated in importance for one-to-one and group conversation. STUDY SAMPLE: Thirty-five adults with normal and impaired hearing. RESULTS: Seven clusters were identified: (1) Being able to listen easily; (2) Being spoken to in a helpful way; (3) Being engaged and accepted; (4) Sharing information as desired; (5) Perceiving flowing and balanced interaction; (6) Feeling positive emotions; (7) Not having to engage coping mechanisms. Three clusters (1, 2, and 4) were more important in group than in one-to-one conversation. There were no differences by hearing group. CONCLUSIONS: These findings emphasise that conversation success is a multifaceted concept.

Assessment of Hearing-Related Lifestyle Based on the Common Sound Scenarios Framework.

PURPOSE: Auditory lifestyle can play a role in hearing care needs, and, as such, it needs to be considered when treating people with hearing loss. In this study, we propose a questionnaire consisting of 24 listening situations based on the Common Sound Scenarios (CoSS) framework. METHOD: Seventeen experienced hearing aid (HA) users filled out the Hearing-Related Lifestyle Questionnaire four times: Days 1, 2, 15, and 29. The questionnaire consisted of 24 listening situations that participants rated on frequency of occurrence, importance to hear well, difficulty to hear, and HA satisfaction. Four questionnaire outcomes were extracted from these ratings: richness of hearing-related lifestyle, hearing demand, hearing difficulty, and HA satisfaction. Additionally, the participants were asked whether any listening situations are not understandable or relatable, whether any situations are missing from the questionnaire, and whether the number of questions is acceptable. Test-retest reliability analyses were done to assess whether the questionnaire outcomes are reliable across the four reports. Correlation analyses were done to assess whether there is a relationship between the questionnaire outcomes. RESULTS: The questionnaire outcomes have excellent reliability. The listening situations in the questionnaire are generally complete and relatable, and the number of questions is acceptable. Correlation analyses revealed that the questionnaire outcomes are related to each other. CONCLUSIONS: Currently, there are no other hearing-related lifestyle questionnaires that purely assess listening situations. The proposed questionnaire has the potential to add to our understanding of hearing-related lifestyle of people needing or undergoing hearing care. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21514044.

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.

Live Evaluation of Auditory Preference, a Laboratory Test for Evaluating Auditory Preference.

BACKGROUND: Many laboratory tests are performed under unrealistic conditions. Tasks, such as repeating words or sentences, are performed in simple loudspeaker setups. Currently, many research groups focus on realistic audiovisual laboratory setups. Fewer groups focus on the tasks performed during testing. PURPOSE: A semicontrolled laboratory test method focusing on the tasks performed, the Live Evaluation of Auditory Preference (LEAP) was evaluated. LEAP is developed to evaluate hearing-instrument performance in test scenarios that represent everyday listening situations. RESEARCH DESIGN: LEAP was evaluated in a feasibility study. The method comprises conversations between a test participant and one or two test leaders, enabling evaluation of the test participant's own voice. The method allows for visual cues (when relevant) and introduce social pressure to participate in the conversation. In addition, other everyday listening tasks, such as watching television (TV) and listening to radio, are included. In this study, LEAP was used to assess preference for two hearing aid settings using paired comparisons. STUDY SAMPLE: Nineteen experienced hearing aid users (13 females and 6 males; mean age 74 years), participated in the study. DATA COLLECTION AND ANALYSIS: LEAP was performed at three visits to the laboratory. In addition, participants conducted a field trial where the two hearing aid programs were compared using Ecological Momentary Assessments (EMA). During LEAP testing, six mandatory test cases were used, representing commonly occurring everyday listening situations. Individual test cases were also included, selected from individually experienced listening situations during the field trial. Within- and between-session reliability of the LEAP test was investigated. Validity was investigated by comparing the LEAP and the EMA results. RESULTS: For the current signal-processing evaluation, the test was judged to have acceptable reliability and validity. The inclusion of individually selected test cases increased the representativeness of the LEAP test, but it did not substantially alter the results in the current study. CONCLUSION: LEAP in its current implementation seems suitable for investigating signal-processing preference in the laboratory in a way that is indicative of everyday preference. The LEAP method represents one step forward in bringing the real world into the laboratory.

Selecting Scenarios for Hearing-Related Laboratory Testing.

For hearing aid users to experience everyday benefit from their hearing aids, research, development, and fitting of hearing aids must be performed using evaluation methods that are indicative of everyday performance. These evaluations can take place both in peoples' ordinary lives and in laboratory settings. For the results of laboratory testing to be ecologically valid, the selected test scenarios must capture the essence of everyday listening. The present article discusses the selection of these laboratory test scenarios in three parts. Part 1 reviews prior research on the selection of everyday listening situations for laboratory testing and discusses realistic test scenarios as important research tools. Part 2 presents findings from an ecological momentary assessments study in which 19 experienced hearing aid users reported real-time auditory reality data, including their current listening activity and their current sound environment. Participants categorized their listening situations according to the common sound scenarios framework and rated how often each situation occurred, how important it was to hear well, and how difficult it was to hear in the situation. These ratings made it possible to filter the data according to three criteria (occurrence, importance, and difficulty). The filtered data could potentially be used for selecting laboratory test scenarios. Part 3 uses the data from Part 2 and data from the studies reviewed in Part 1 to broadly explore the test scenarios that various selection criteria lead to. Further, implementation of test scenarios in the laboratory, and the strengths and limitations of data collection methods for investigating auditory reality are briefly discussed. The article concludes with a summary of the collected study.

The Quest for Ecological Validity in Hearing Science: What It Is, Why It Matters, and How to Advance It.

Ecological validity is a relatively new concept in hearing science. It has been cited as relevant with increasing frequency in publications over the past 20 years, but without any formal conceptual basis or clear motive. The sixth Eriksholm Workshop was convened to develop a deeper understanding of the concept for the purpose of applying it in hearing research in a consistent and productive manner. Inspired by relevant debate within the field of psychology, and taking into account the World Health Organization's International Classification of Functioning, Disability, and Health framework, the attendees at the workshop reached a consensus on the following definition: "In hearing science, ecological validity refers to the degree to which research findings reflect real-life hearing-related function, activity, or participation." Four broad purposes for striving for greater ecological validity in hearing research were determined: A (Understanding) better understanding the role of hearing in everyday life; B (Development) supporting the development of improved procedures and interventions; C (Assessment) facilitating improved methods for assessing and predicting ability to accomplish real-world tasks; and D (Integration and Individualization) enabling more integrated and individualized care. Discussions considered the effects of variables and phenomena commonly present in hearing-related research on the level of ecological validity of outcomes, supported by examples from a few selected outcome domains and for different types of studies. Illustrated with examples, potential strategies were offered for promoting a high level of ecological validity in a study and for how to evaluate the level of ecological validity of a study. Areas in particular that could benefit from more research to advance ecological validity in hearing science include: (1) understanding the processes of hearing and communication in everyday listening situations, and specifically the factors that make listening difficult in everyday situations; (2) developing new test paradigms that include more than one person (e.g., to encompass the interactive nature of everyday communication) and that are integrative of other factors that interact with hearing in real-life function; (3) integrating new and emerging technologies (e.g., virtual reality) with established test methods; and (4) identifying the key variables and phenomena affecting the level of ecological validity to develop verifiable ways to increase ecological validity and derive a set of benchmarks to strive for.

Bayesian analysis of paired-comparison sound quality ratings.

This paper presents a method to analyze paired-comparison data including either binary or graded ordinal responses, with or without ties. The proposed method can use either of two classical choice models: (1) Thurstone case V, which assumes a Gaussian distribution of the sensory variables underlying listener decisions, or (2) the Bradley-Terry-Luce (BTL) model, which assumes a logistic distribution. The analysis method was validated using simulated paired-comparison experiments with known distributions of the sound-quality parameters in the simulated population from which "participants" were generated at random. The validation indicated that the Thurstone and BTL models give similar results close to the true values. The estimated credibility of a quality difference was slightly higher with the BTL model. The analysis results showed dramatically better precision when the response data included graded ordinal judgments instead of binary responses. Allowing tied responses also tended to improve precision. The method was also applied to data from a real evaluation of hearing-aid programs. The analysis revealed clinically interesting results with high statistical credibility, although the amount of test data was limited.

Common Sound Scenarios: A Context-Driven Categorization of Everyday Sound Environments for Application in Hearing-Device Research.

BACKGROUND: Evaluation of hearing-device signal-processing features is performed for research and development purposes, but also in clinical settings. Most people agree that the benefit experienced in a hearing-device user's daily life is most important, but laboratory tests are popular since they can be performed uniformly for all participants in a study using sensitive outcome measures. In order to design laboratory tests that have the potential of indicating real-life benefit, there is a need for more information about the acoustic environments and listening situations encountered by hearing-device users as well as by normal-hearing people. PURPOSE: To investigate the acoustic environments and listening situations people encounter, and to provide a structured framework of common sound scenarios (CoSS) that can be used for instance when designing realistic laboratory tests. RESEARCH DESIGN: A literature search was conducted. Extracted acoustic environments and listening situations were categorized using a context-based approach. A set of common sound scenarios was established based on the findings from the literature. DATA COLLECTION: A number of publications providing data on encountered acoustic environments and listening situations were identified. Focus was on studies including informants who reported or recorded information in field trials. Nine relevant references were found. In combination with data collected at our laboratory, 187 examples of acoustic environments or listening situations were found. RESULTS: Based on the extracted data, a categorization approach based on context (intentions and tasks) was used when creating CoSS. Three intention categories, "speech communication," "focused listening," and "nonspecific" were divided into seven task categories. In each task category, two sound scenarios were described, creating in total 14 common sound scenarios. The literature search showed a general lack of studies investigating acoustic environments and listening situations, in particular studies where normal-hearing informants are included and studies performed outside North America and Western Europe. CONCLUSIONS: A structured framework was developed. Intentions and tasks constitute the main categories in the framework, and 14 common sound scenarios were selected and described. The framework can for instance be used when developing hearing-device signal-processing features, in the evaluation of such features in realistic laboratory tests, and for demonstration of feature effects to hearing-device wearers.

Estimation of Signal-to-Noise Ratios in Realistic Sound Scenarios.

BACKGROUND: Both in the design of hearing-device features, such as noise reduction, and in the evaluation measurements of such features, there is a need for more information about the sound scenarios hearing-device users encounter. The limitations of adaptive speech tests as outcome measures in the evaluation of hearing-device features have been discussed. The obvious alternative to adaptive speech testing is to test at a fixed signal-to-noise ratio (SNR). However, the question is which SNRs should be used if the test reflects real-life situations. PURPOSE: The purpose of this study was to estimate SNRs in realistic sound environments encountered by hearing aid users. RESEARCH DESIGN: Research design was a descriptive study where recorded sound files were statistically analyzed. STUDY SAMPLE: A total of 20 experienced, bilaterally fitted hearing aid users, all satisfied with their current hearing aids, made recordings for 3-4 days. The informants were instructed to record different situations in daily life and were told that all situations were of equal importance. The informants ranged in age from 18-81 yr old, and they had various occupations and varying hearing-loss configurations. DATA COLLECTION AND ANALYSIS: The total duration of the recorded material for each informant was, on average, 84 min; the number of recordings was, on average, 17 per informant. The sound files were categorized based on the type of background noise and were analyzed with use of a manual noise estimation procedure. Segments of speech with noise present were cut out from the original recordings. Corresponding noise-only segments were also extracted. On the basis of power calculations for these two types of recorded segments, the SNR was estimated. Frequency-specific and overall SNRs, calculated both based on unweighted and A-weighted speech and noise levels, were derived. An estimation uncertainty measure was also developed. RESULTS: The range of SNRs found in the material was large. The most striking finding was that there were very few recorded situations where the SNR was negative or even close to 0 dB. For speech-in-babble noise, the average SNR was approximately 5 dB. The estimation uncertainty was generally low but became higher in highly fluctuating noises and at very low SNRs. CONCLUSIONS: The estimated SNRs were higher than previously reported. The results can be used in the design and evaluation of hearing-device features.

Comparison of predictive measures of speech recognition after noise reduction processing.

A number of measures were evaluated with regard to their ability to predict the speech-recognition benefit of single-channel noise reduction (NR) processing. Three NR algorithms and a reference condition were used in the evaluation. Twenty listeners with impaired hearing and ten listeners with normal hearing participated in a blinded laboratory study. An adaptive speech test was used. The speech test produces results in terms of signal-to-noise ratios that correspond to equal speech recognition performance (in this case 80% correct) with and without the NR algorithms. This facilitates a direct comparison between predicted and experimentally measured effects of noise reduction algorithms on speech recognition. The experimental results were used to evaluate nine different predictive measures, one in two variants. The best predictions were found with the Coherence Speech Intelligibility Index (CSII) [Kates and Arehart (2005), J. Acoust. Soc. Am. 117(4), 2224-2237]. In general, measures using correlation between the clean speech and the processed noisy speech, as well as other measures that are based on short-time analysis of speech and noise, seemed most promising.

Preferred overall loudness. I: Sound field presentation in the laboratory.

This study questions the basic assumption that prescriptive methods for nonlinear, wide dynamic range compression (WDRC) hearing aids should restore overall loudness to normal. Fifteen normal-hearing listeners and twenty-four hearing-impaired listeners (with mild to moderate hearing loss, twelve with and twelve without hearing aid experience) participated in laboratory tests. The participants first watched and listened to video sequences and rated how loud and how interesting the situations were. For the hearing-impaired participants, gain was applied according to the NAL-NL1 prescription. Despite the fact that the NAL-NL1 prescription led to less than normal overall calculated loudness, according to the loudness model of Moore and Glasberg (1997), the hearing-impaired participants rated loudness higher than the normal-hearing participants. The participants then adjusted a volume control to preferred overall loudness. Both normal-hearing and hearing-impaired participants preferred less than normal overall calculated loudness. The results from the two groups of hearing-impaired listeners did not differ significantly.

Preferred overall loudness. II: Listening through hearing aids in field and laboratory tests.

In a laboratory study, we found that normal-hearing and hearing-impaired listeners preferred less than normal overall calculated loudness (according to a loudness model of Moore & Glasberg, 1997). The current study verified those results using a research hearing aid. Fifteen hearing-impaired and eight normal-hearing participants used the hearing aid in the field and adjusted a volume control to give preferred loudness. The hearing aid logged the preferred volume control setting and the calculated loudness at that setting. The hearing-impaired participants preferred, in median, loudness levels of -14 phon re normal for input levels from 50 to 89 dB SPL. The normal-hearing participants preferred close to normal overall loudness. In subsequent laboratory tests, using the same hearing aid, both hearing-impaired and normal-hearing listeners preferred less than normal overall calculated loudness, and larger reductions for higher input levels In summary, the hearing-impaired listeners preferred less than normal overall calculated loudness, whereas the results for the normal-hearing listeners were inconclusive.

Is normal or less than normal overall loudness preferred by first-time hearing aid users?

OBJECTIVE: Most prescriptive methods for nonlinear, wide dynamic range compression (WDRC) hearing aids are based on the assumption that a hearing-impaired listener should perceive amplified sounds at the same overall loudness as would a normal-hearing listener without amplification. However, some previous research on linear amplification has indicated that subjects prefer less overall gain than prescribed by the most commonly used prescriptive method for linear hearing aids, NAL-R, a method that gives close to normal overall loudness for a mid-level input. The current study aims at comparing two prescriptive methods for WDRC hearing aids. The methods differ in the overall loudness they aim to give the hearing aid user. One method, called NormLoudn, is based on a generic method that prescribes gain so that the overall loudness is restored to normal. Another method, called LessLoudn, is based on a hearing aid specific prescription, and gives the hearing aid user less than normal overall loudness. Do first-time hearing aid users prefer the method that restores overall loudness to normal or the method that gives less than normal overall loudness? DESIGN: Twenty-one first-time hearing aid users with typical hearing losses for this group of clients participated in a crossover blinded field study where the two fitting methods were compared using a multi-programmable hearing aid, Danalogic 163D. Preference in the field was evaluated using interview, questionnaire, and diary. The field test was accompanied by laboratory tests, which included paired comparison judgments of preference and loudness and a speech recognition test. Loudness calculations were also used when interpreting the results, and a theoretical comparison with other prescriptive methods for WDRC hearing aids was made. RESULTS: After necessary adjustments, the measured gain for the two methods was similar in gain-frequency shape, but NormLoudn gave more overall gain than LessLoudn. Generally, NormLoudn fittings led to calculated overall loudness that was close to normal, whereas LessLoudn fittings, in median, led to 3-7 phon less than normal calculated overall loudness according to the loudness model used. During the interview performed after the field test, 19 out of the 21 subjects stated that they preferred LessLoudn. Also the questionnaire and the diary showed a clear preference for LessLoudn in all types of listening situations. Paired comparisons of preference in the laboratory supported the findings in the field. LessLoudn was preferred to NormLoudn in all tested situations, except for soft speech in very soft noise where there was no significant preference for either method. Speech recognition scores were similar for the two fittings. The difference in calculated loudness was clearly distinguishable to the subjects and seemed to govern their preferences. CONCLUSIONS: LessLoudn, which gave less than normal overall loudness according to the loudness model used, was preferred both in the field and in the laboratory tests. Speech recognition scores were similar for both methods. A comparison between the measured gain for NormLoudn and the gain prescribed by CAMEQ, NAL-NL1, and DSL[i/o], suggests that all three prescriptive procedures (DSL[i/o] in particular) would probably overestimate the required gain for subjects without hearing aid experience and with mild to moderate hearing loss. When providing these clients with hearing aids, it seems important to include a careful adjustment of the overall gain to avoid overamplification if the prescription used aims at restoring overall loudness to normal according to the loudness model used here.