Hearing impaired persons' experiences with the online Swedish Individualized Active Communication Education (I-ACE) program: A feasibility study.

Even with optimally fitted hearing aids, many individuals with hearing impairment struggle to hear in situations with difficult listening conditions. Active Communication Education (ACE) is an interactive group rehabilitation program aimed at helping people with hearing loss communicate more effectively using communication strategies to better cope with everyday life. To increase accessibility and allow more people to benefit from the ACE program, a modified individualized version was created. The purpose of this study was to examine the feasibility of providing the Swedish Individualized Active Communication Education (I-ACE) program via an online platform and to explore hearing impaired persons' experiences with the program. For five weeks, ten participants completed the Swedish I-ACE through an online platform. The participants were assigned a new chapter to complete each week and later received individual feedback on their work via the platform. The participants were asked to complete an evaluation form regarding the content and their experiences during and after completing the I-ACE. They were later interviewed to provide more detailed information on their experiences with the program. The program completion rate was 80 %. Participants found the I-ACE program to be informative and relevant but somewhat repetitive. However, only a few participants thought of the repetitiveness as negative. Few participants reported difficulties using the platform. This study indicated that it is feasible to provide the I-ACE program via an online platform and that the content of the program is informative, relevant, and comprehensible. Further research evaluating the effects of the I-ACE is warranted.

Experiences of an Internet-based aural rehabilitation (IAR) program for hearing aid users: a qualitative study.

OBJECTIVE: Internet interventions for hearing aid (HA) users have been shown to be effective in helping persons with hearing problems. As earlier research refers to objective data on these effects, little is known about how participants experience the Internet interventions subjectively. The aim of the present study was to explore participants' experiences of an Internet-based aural rehabilitation (IAR) program for HA-users, and to explore the possible subjective benefits of such a program. DESIGN: A qualitative exploratory design was implemented involving semi-structured telephone interviews. The interviews were transcribed and analysed using content analysis. STUDY SAMPLE: Interviews were conducted with 20 participants (9 men and 11 women) who had completed an IAR program for HA-users. The participants were 57-81 years old and had used HAs for 2-25 years. RESULTS: The results are organised in three main categories: general experiences associated with participating in the program, knowledge obtained from the program and perceived impact of taking part in the program. CONCLUSIONS: The overall results indicate positive experiences of the IAR program, and an overreaching theme of increased self-esteem was identified. The findings provide some valuable information for developers of future IAR programs.

Usability and Online Audiological Rehabilitation.

PURPOSE: This paper describes the results from the iterative development and usability testing of an online audiological rehabilitation (OAR) program. The OAR was based on previous experience with Internet interventions and OAR. METHOD: The described OAR consisted of weekly learning modules, each of which had a specific topic and contained information and learning activities. A virtual coach, a trained audiologist, led the participants through the modules. The participants' feedback was collected using the "think-aloud" method in which the participants gave their feedback in a structured manner. RESULTS: The early findings from the first version of the OAR showed that participants had difficulty navigating the system. As a result of the usability testing, a second major edition of the OAR program was developed, and the participants found it easier to manage and that it enhanced the learning experience. The participants appreciated the testimonial videos as well as the option to study more in-depth material for a given subject. CONCLUSIONS: The early findings from the usability test of the program provided useful information as to how content can be developed and delivered for optimal user accessibility within the scope of OAR.

Danish reading span data from 283 hearing-aid users, including a sub-group analysis of their relationship to speech-in-noise performance.

OBJECTIVE: This study provides descriptive statistics of the Danish reading span (RS) test for hearing-impaired adults. The combined effect of hearing loss, RS score, and age on speech-in-noise performance in different spatial settings was evaluated in a subset of participants. DESIGN: Data from published and unpublished studies were re-analysed. Data regarding speech-in-noise performance with co-located or spatially separated sound sources were available for a subset of participants. STUDY SAMPLE: RS scores from 283 hearing-impaired participants were extracted from past studies, and 239 of these participants had completed a speech-in-noise test. RESULTS: RS scores (mean = 41.91%, standard deviation = 11.29%) were related to age (p <0.01), but not pure-tone average (PTA) (p = 0.29). Speech-in-noise performance for co-located sound sources was related to PTA and RS score (both p < 0.01, adjusted R-squared = 0.226). Performance for spatially separated sounds was related to PTA (p < 0.01, adjusted R-squared = 0.10) but not RS score (p = 0.484). We found no differences between the standardized coefficients of the two regression models. CONCLUSIONS: The distribution of RS scores indicated a high test difficulty. We found that age should be controlled when RS scores are compared across populations. The experimental setup of the speech-in-noise test may influence the relationship between performance and RS score.

Readability of Internet Information on Hearing: Systematic Literature Review.

PURPOSE: This systematic literature review asks the following question: " What is the readability of Internet information on hearing that people with hearing impairment and their significant others can access in the context of their hearing care?" METHOD: Searches were completed in three databases: CINAHL, PubMed, and Scopus. Seventy-eight records were identified and systematically screened for eligibility: 8 records were included that contained data on the readability of Internet information on hearing that people with hear ing impairment and their significant others can access in the context of their hearing care. RESULTS: Records reported mean readability levels from 9 to over 14. In other words, people with hearing impairment and their significant others need 9 to 14 years of education to read and understand Internet information on hearing that they access in the context of their hearing care. CONCLUSION: The poor readability of Internet information on hearing has been well documented; it is time to focus on valid and sustainable initiatives that address this problem.

Internet Interventions for Hearing Loss.

PURPOSE: The purpose of the two studies presented in this research forum article was to develop audiological rehabilitation programs for experienced hearing aid users and evaluate them in online versions. In this research forum article, the differences between the two studies are discussed. METHOD: Two randomized controlled trials (RCTs) were performed evaluating the efficacy of online rehabilitation, including professional guidance by an audiologist. In each RCT, the effects of the online programs were compared with the effects measured in a control group. RESULTS: The results from the first RCT showed a significant increase in activity and participation for both groups with participants in the intervention group improving more than those in the control group. At the 6-month follow-up, after the study, the significant increase was maintained; however, amounts of increase in the two groups were no longer significantly different. The results from the second RCT showed significant increase in activity and participation for the intervention group, although the control group did not improve. CONCLUSIONS: The results from the RCTs provide evidence that the Internet can be used to deliver rehabilitation to hearing-aid users and that their problems are reduced by the intervention; however, the content of the online rehabilitation program requires further investigation.

A randomized controlled trial evaluating the effects of online rehabilitative intervention for adult hearing-aid users.

OBJECTIVE: Previous research shows that the internet can be used in the rehabilitation of hearing-aid users. By further developing the online program, it might be possible to foster behavioral changes that will positively affect hearing-aid users. DESIGN: A randomized controlled study with two groups of participants. The intervention group underwent a five-week online intervention while the control group was referred to a waiting list. Questionnaires were used as outcome measures. STUDY SAMPLE: Seventy-six experienced hearing-aid users participated in the study, ranging in age from 26 to 81 years (mean 69.3 years). RESULTS: The findings showed significant improvements in the intervention group after the intervention, measured by the hearing handicap inventory for the elderly. The effects were maintained and improved at the follow-up. Furthermore, the results indicated that the participants in the intervention group improved at two items of the international outcome inventory for hearing aids, and the effects were partly maintained at the follow-up. Finally, significant improvements in the domain of psychosocial wellbeing were found at the follow-up. CONCLUSIONS: This study provides further evidence that the internet can be used to deliver intervention of rehabilitation to hearing-aid users.

Internet access and use in adults with hearing loss.

BACKGROUND: The future rehabilitation of adults with hearing loss is likely to involve online tools used by individuals at home. Online tools could also be useful for people who are not seeking professional help for their hearing problems. Hearing impairment is a disability that increases with age, and increased age is still associated with reduced use of the Internet. Therefore, to continue the research on online audiological rehabilitative tools for people with hearing loss, it is important to determine if and to what extent adults with hearing loss use the Internet. OBJECTIVE: To evaluate the use of the Internet and email in a group of adults with hearing loss and to investigate if their use of Internet and email differed between genders, among different age groups, and how it compared with the general population in Sweden. METHODS: Questionnaires containing multiple-choice questions about Internet access, email use, and educational level were mailed to individuals with hearing loss, who were registered as patients at a hearing aid clinic. Out of the 269 invited participants, 158 returned a completed questionnaire, which was a response rate of 58.7%. RESULTS: The results showed that 60% (94/158) of the participants with hearing loss used computers and the Internet. The degree of hearing loss in the group of participants did not explain the level of Internet usage, while factors of age, gender, and education did (P<.001). More men than women used the Internet (OR 2.54, 95% CI 1.32-4.91, P<.001). Use of the Internet was higher in the youngest age group (25-64 years) compared to the oldest age group (75-96 years, P=.001). A higher usage of the Internet was observed in the participants with hearing loss, especially the elderly, when compared with the general population of Sweden (OR 1.74, 95% CI 1.23-3.17, P=.04). CONCLUSIONS: We conclude that the use of computers and the Internet overall is at least at the same level for people with hearing loss as for the general age-matched population in Sweden, but that this use is even higher in specific age groups. These results are important for the future work in developing and evaluating rehabilitative educational online tools for adults with hearing loss.

The use of research questionnaires with hearing impaired adults: online vs. paper-and-pencil administration.

BACKGROUND: When evaluating hearing rehabilitation, it is reasonable to use self-report questionnaires as outcome measure. Questionnaires used in audiological research are developed and validated for the paper-and-pencil format. As computer and Internet use is increasing, standardized questionnaires used in the audiological context should be evaluated to determine the viability of the online administration format.The aim of this study was to compare administration of questionnaires online versus paper- and pencil of four standardised questionnaires used in hearing research and clinic. We included the Hearing Handicap Inventory for the Elderly (HHIE), the International Outcome Inventory for Hearing Aids (IOI-HA), Satisfaction with Amplification in Daily Life (SADL), and the Hospital Anxiety and Depression Scale (HADS). METHODS: A cross-over design was used by randomly letting the participants complete the questionnaires either online or on paper. After 3 weeks the participants filled out the same questionnaires again but in the other format. A total of 65 hearing-aid users were recruited from a hearing clinic to participate on a voluntary basis and of these 53 completed both versions of the questionnaires. RESULTS: A significant main effect of format was found on the HHIE (p < 0.001), with participants reporting higher scores on the online format than in the paper format. There was no interaction effect. For the other questionnaires were no significant main or interaction effects of format. Significant correlations between the two ways of presenting the measures was found for all questionnaires (p<0.05). The results from reliability tests showed Cronbachs α's above .70 for all four questionnaires and differences in Cronbachs α between administration formats were negligible. CONCLUSIONS: For three of the four included questionnaires the participants' scores remained consistent across administrations and formats. For the fourth included questionnaire (HHIE) a significant difference of format with a small effect size was found. The relevance of the difference in scores between the formats depends on which context the questionnaire is used in. On balance, it is recommended that the administration format remain stable across assessment points.

Working memory capacity may influence perceived effort during aided speech recognition in noise.

BACKGROUND: Recently there has been interest in using subjective ratings as a measure of perceived effort during speech recognition in noise. Perceived effort may be an indicator of cognitive load. Thus, subjective effort ratings during speech recognition in noise may covary both with signal-to-noise ratio (SNR) and individual cognitive capacity. PURPOSE: The present study investigated the relation between subjective ratings of the effort involved in listening to speech in noise, speech recognition performance, and individual working memory (WM) capacity in hearing impaired hearing aid users. RESEARCH DESIGN: In two experiments, participants with hearing loss rated perceived effort during aided speech perception in noise. Noise type and SNR were manipulated in both experiments, and in the second experiment hearing aid compression release settings were also manipulated. Speech recognition performance was measured along with WM capacity. STUDY SAMPLE: There were 46 participants in all with bilateral mild to moderate sloping hearing loss. In Experiment 1 there were 16 native Danish speakers (eight women and eight men) with a mean age of 63.5 yr (SD = 12.1) and average pure tone (PT) threshold of 47. 6 dB (SD = 9.8). In Experiment 2 there were 30 native Swedish speakers (19 women and 11 men) with a mean age of 70 yr (SD = 7.8) and average PT threshold of 45.8 dB (SD = 6.6). DATA COLLECTION AND ANALYSIS: A visual analog scale (VAS) was used for effort rating in both experiments. In Experiment 1, effort was rated at individually adapted SNRs while in Experiment 2 it was rated at fixed SNRs. Speech recognition in noise performance was measured using adaptive procedures in both experiments with Dantale II sentences in Experiment 1 and Hagerman sentences in Experiment 2. WM capacity was measured using a letter-monitoring task in Experiment 1 and the reading span task in Experiment 2. RESULTS: In both experiments, there was a strong and significant relation between rated effort and SNR that was independent of individual WM capacity, whereas the relation between rated effort and noise type seemed to be influenced by individual WM capacity. Experiment 2 showed that hearing aid compression setting influenced rated effort. CONCLUSIONS: Subjective ratings of the effort involved in speech recognition in noise reflect SNRs, and individual cognitive capacity seems to influence relative rating of noise type.

Rehabilitative online education versus internet discussion group for hearing aid users: a randomized controlled trial.

BACKGROUND: By using the Internet in the audiological rehabilitation process, it might be possible in a cost-effective way to include additional rehabilitation components by informing and guiding hearing aid users about such topics as communication strategies, hearing tactics, and how to handle hearing aids. PURPOSE: To evaluate the effectiveness of an online education program for adult experienced hearing aid users including professional guidance by an audiologist and compare it with the effects of participation in an online discussion forum without any professional contact. RESEARCH DESIGN: A randomized controlled study with two groups of participants. Repeated measures at prestudy, immediate follow-up, and a 6 mo follow-up. STUDY SAMPLE: Fifty-nine experienced hearing aid users participated in the study, ranging in age from 24 to 84 yr (mean 63.5 yr). INTERVENTION: The intervention group (N = 29) underwent a five-week rehabilitative online education in which activities for each week included information, tasks, and assignments, and contact with a professional audiologist was included. The participants in the control group (N = 30) were referred to an online discussion forum without any audiologist contact. DATA COLLECTION AND ANALYSIS: A set of questionnaires administered online were used as outcome measures: (1) Hearing Handicap Inventory for the Elderly, (2) International Outcome Inventory for Hearing Aids, (3) Satisfaction with Amplification in Daily Life, and (4) Hospital Anxiety and Depression Scale. RESULTS: Significant improvements measured by the Hearing Handicap Inventory for the Elderly were found in both groups of participants, and the effects were maintained at the 6 mo follow-up. The results on the Hospital Anxiety and Depression Scale showed that the participants in the intervention group showed reduced symptoms of depression immediately/6 mo after the intervention. At the 6 mo follow-up participants in the control group reported fewer symptoms of anxiety than they did before the intervention started. CONCLUSIONS: This study provides preliminary evidence that the Internet can be used to deliver education to experienced hearing aid users who report residual hearing problems such that their problems are reduced by the intervention. The study also suggests that online discussion forums could be used in rehabilitation. A combination of online professional supervised education and online informal discussions could be a promising rehabilitation tool.

Phonological mismatch and explicit cognitive processing in a sample of 102 hearing-aid users.

Rudner et al (2008) showed that when compression release settings are manipulated in the hearing instruments of Swedish habitual users, the resulting mismatch between the phonological form of the input speech signal and representations stored in long-term memory leads to greater engagement of explicit cognitive processing under taxing listening conditions. The mismatch effect is manifest in significant correlations between performance on cognitive tests and aided-speech-recognition performance in modulated noise and/or with fast compression release settings. This effect is predicted by the ELU model (Rönnberg et al, 2008). In order to test whether the mismatch effect can be generalized across languages, we examined two sets of aided speech recognition data collected from a Danish population where two cognitive tests, reading span and letter monitoring, had been administered. A reanalysis of all three datasets, including 102 participants, demonstrated the mismatch effect. These findings suggest that the effect of phonological mismatch, as predicted by the ELU model (Rönnberg et al, this issue) and tapped by the reading span test, is a stable phenomenon across these two Scandinavian languages.

Interactions between cognition, compression, and listening conditions: effects on speech-in-noise performance in a two-channel hearing aid.

This study which included 23 experienced hearing aid users replicated several of the experiments reported in Gatehouse et al (2003, 2006) with new speech test material, language, and test procedure. The performance measure used was SNR required for 80% correct words in a sentence test. Consistent with Gatehouse et al, this study indicated that subjects showing a low score in a cognitive test (visual letter monitoring) performed better in the speech recognition test with slow time constants than with fast time constants, and performed better in unmodulated noise than in modulated noise, while subjects with high scores on the cognitive test showed the opposite pattern. Furthermore, cognitive test scores were significantly correlated with the differential advantage of fast-acting versus slow-acting compression in conditions of modulated noise. The pure tone average threshold explained 30% of the variance in aided speech recognition in noise under relatively simple listening conditions, while cognitive test scores explained about 40% of the variance under more complex, fluctuating listening conditions, where the pure tone average explained less than 5% of the variance. This suggests that speech recognition under steady-state noise conditions may underestimate the role of cognition in real-life listening.