The hearing aid effect: challenges for counseling.

Over 22 million Americans are diagnosed with hearing losses. Approximately 1.4 million hearing aids are sold annually (Shimon, 1992) in an effort to deal with this communication disability. The stigma associated with the wearing of hearing aids may preclude the necessary commitment of clients to wear their hearing aids. The tradeoff between social acceptance, vanity, personal appraisal about aging, and other issues may play a pivotal role in improving the quality of lives for millions of Americans with hearing losses.

Hearing loss affects communication in a number of ways but primarily by decreasing the intensity of the speech signal and the clarity of the words and message. According to Hull (1997), "feelings of embarrassment, frustration, anger, defeat and ultimate withdrawal from situations that require communication are very real among older persons who are hearing impaired" (p. 326). LaFerle and LaFerle (1988) indicated that hearing loss in the presence of other limitations, especially in the elderly, may result in depression and self-isolation. The effects of hearing loss vary from speaker to speaker and the adjustment to hearing loss is a unique experience for each person. For some people conversations may sound muffled or unclear, while another person may barely hear any sound even when amplified with a hearing aid. Hearing aid wearers must be prepared to wear hearing aids, become active and informed consumers, understand the benefits of the aids, and learn to adjust to the experience of wearing these mechanical devices.

Typically, individuals needing hearing aids have little or inaccurate information that may be misunderstood from television, magazine advertisements, or anecdotes from family and friends. Therefore, the need for informational and supportive counseling for first time wearers is critical. According to Warren and Daily (1984), even when individuals are provided with appropriate informational counseling they may not wear hearing aids because of the strong desire to pass for "socially normal" or younger. Rupp, Higgins, and Maurer (1977) considered motivation the most important factor in the successful adaptation and use of hearing aids. Kasten (1992) indicated that there were nine important factors that should be considered when determining the appropriateness of dispensing hearing aids including: motivation, adaptability, personal appraisal, money, social context, personal influence, mobility, vanity, and manual dexterity. According to Hull (1997) clients who can see the benefits of acoustic amplification over other issues such as vanity, negative personal appraisals, or unrealistic expectation for hearing aids appear to successfully adapt to wearing hearing aids. The awareness of the existence of a hearing loss and the acceptance of the need for an assistive device are critical steps in adjUstment to hearing aids.

Unfortunately, hearing aids have not gained the same popular acceptance as eyeglasses or contact lenses. Himber (1989) in discussing her own "surviving" of hearing loss described that she "was gripped by resentment that this widespread impairment remained underground, whereas millions of people with poor vision could display their problem openly ......Why should I have come to expect a harmless unit tucked behind my ear to prompt such uneasiness in everyone who caught sight of it?" (p. 90).

Over a decade before Himber's personal account, Blood, Blood, and Danhauer (1977) reported that the mere presence of a hearing aid prompted raters to evaluate individuals more negatively on the dimensions of intelligence, achievement, personality, and appearance. The authors labeled the stigma associated with wearing a hearing aid the "Hearing Aid Effect." Continued research showed that the "Hearing Aid Effect" was found in hearing impaired and deaf school-age children when evaluated by college students, school age peers, classroom teachers, or speech language pathologists and audiologists (Blood, Blood, & Danhauer, 1978; Blood & Blood, 1982; Blood & Blood, 1983; Danhauer, Blood, Blood, & Gomez, 1980; Dengerink & Porter, 1984). The stigma was also reported in elderly individuals evaluated by their elderly peers (Johnson & Danhauer, 1982) and college students (Mulac, Danhauer, & Johnson, 1983). Since the results of those first studies were published, hearing aid manufacturers have addressed the cosmetic satisfaction issues of consumers and significantly reduced the size and visibility of the hearing aid. However, many clients still have amplification needs which necessitate a highly visible hearing aid. Clients need to learn about the technology and maintenance of these assistive listening devices and also how to deal with communication problems encountered with significant others in work and social environments. Informational counseling plays an integral role in helping fist time wearers adjust to their hearing aids. Issues involving the cosmetics of the hearing aid (size and visibility), keeping background noise to a minimum (talking in smaller groups, moving away from noise interference), or reducing the distance from the speaker are a few of the tactics for improving communication and assisting with overall adjustment to the hearing aid.

This study was designed to determine if the degree to which the "cosmetic versus acoustic performance" dilemma still exists. Hearing health care professionals and counselors need to be aware that some clients may be overly sensitive to the presence of a hearing aid as a marker for aging and "dependence" (Kasten, 1992; Hull, 1997) and therefore require additional counseling about the benefits of amplification. The present study is part of an ongoing series of investigations about perceptions of individuals with communication disabilities. The specific aim of the study was to determine subjects' preference for cosmetics (size and visibility of a hearing aid) compared to increased speech understanding and amplification of sound.

Method

Subjects

Subjects for this study were 100 undergraduate students from five disciplines including 24 (24%) communication disorders majors, 16 (16%) engineering majors, 27 (27%) education majors, 15 (15%) nursing majors, and 18 (18%) psychology majors. A total of 63 females and 37 males between the ages of 18 and 32 years of age (mean age 20.2 yrs) volunteered for the study. All subjects had a) normal hearing as defined by pure-tone thresholds hearing thresholds at octave frequencies from 250 Hz to 8000 Hz and speech reception thresholds of [is less than] 25 dB hearing level (American National Standards Institute, 1989), and b) normal middle ear function as defined by guidelines by the American Speech Language Hearing Association (1990).

Stimuli

Scripted, conversational dyads were developed by the author on two topics: a) preparing for difficult examinations, and b) roommate and renting problems. The author requested that five pairs of undergraduate students discuss the two topics while being audio taped. The conversational scripts were compilations from the conversations. Two theater majors (19 yr old male; 20 yr old female) were provided written scripts of five-minute conversations including the following topics: the difficulty of studying for examinations, noise levels in the library, best ways to relax, best techniques for studying, problems with the current roommate referral system, bothersome and noisy neighbors, roommates who wanted to take off the summer and sublet the apartment. Speakers were encouraged to convey a routine and ordinary conversational manner during rehearsals of the scripts. The final audio recordings were duplicated. Copies of the two conversational speech samples were acoustically filtered (elimination of certain sound frequencies) at a rate of 10 dB per octave frequency. The filtering resulted in a simulation audiotape of the most typical pattern of hearing loss reported in adults (high-frequency sloping sensorineural hearing loss). The filtering process eliminated or reduced the cues for high frequency sound recognition which are critical to the accurate understanding of speech. Through this filtering process, the high pitched sounds (e.g., s, z, sh) are less clear and softer. The filtered condition created a listening condition for normal listeners that was similar to the condition that would be experienced by listeners with a hearing loss on a regular basis. This meant that although speech could still be heard and understood, it was softer, required greater attention on the part of the listener and also required the listener to "fill in some words or parts of speech." This would be comparable to a listening situation typical for hearing impaired listeners with this type of hearing loss. The four final stimulus tapes included the two conversational dyads: (a) preparation for examinations and (b) roommate and renting problems under the two conditions: (a)unfiltered and (b) filtered.

Reliability

In order to determine that the two conversational dyads on the audio tapes would be evaluated similarly on content/interest level and would not confound the results of the study, the two unfiltered tapes (the conversational dyed preparing for difficult examinations, and the conversational dyed about roommate and renting problems) were provided to 20 naive listeners ranging in age from 18-22 yrs (mean age 19.6 yrs). Each of the 20 judges was asked to evaluate the two tapes on a scale from I (very interesting) to 7 (very uninteresting). Comparisons of the rater's group mean scores of 3.8 and 4.1 for the tapes revealed no significant differences in the level of interest. This meant that the two scripted conversations were rated as similar in content and would not confound the results.

In order to determine that the filtering conditions had created perceptually different listening conditions, the two filtered and two unfiltered tapes were also rated by the same 20 judges. Each of the 20 judges was asked to rate each of the four tapes (two conversational dyads under two conditions) on a scale of I (very easy to understand; intelligible) to 7 (very difficult to understand; unintelligible). Results revealed significant differences between the tapes recorded in filtered and unfiltered conditions (t(19) = 2.1; p [is greater than] .01), but no significant differences between the two filtered conditions or the two unfiltered conditions. In other words, the only difference among all four of the tapes was the difficulty of the listening conditions.

Procedures

Subjects who passed the selection criteria were informed that they would be participating in a study examining the effects of hearing loss. Subjects were escorted to a listening laboratory where they were instructed to listen to filtered and unfiltered audiotapes through earphones at a comfortable loudness level. They were informed that they would need to listen carefully, as they would be required to answer a series of questions about the conversations at the conclusion of each tape. Twenty five subjects were randomly assigned to one of four groups. Each group heard two tapes. Group I heard a dyed discussing preparation for examinations in the unfiltered condition followed by a dyed discussing roommate and renting problems in the filtered condition. Group 2 heard a dyed discussing roommate and renting problems in the unfiltered condition followed by a dyed discussing preparation for examinations in the filtered condition. Group 3 heard a dyed discussing preparation for examinations in the filtered condition followed by a dyed discussing roommate and renting problems in the unfiltered condition. Group 4 heard a dyed discussing roommate and renting problems in the filtered condition followed by a dyed discussing preparation for examinations recorded in the unfiltered condition.

Listener Responses and Categories

At the end of each audiotape, subjects were asked to answer five questions about the conversations to determine their level of attention and ability to comprehend the message. Answers were assigned I point each with O representing no correct answers and 5 a perfect score. Then subjects were asked the following question: "If your daily hearing level was similar to what you just listened to for the past five minutes, would you wear a hearing aid if you knew it would improve your hearing?" This question was asked to ascertain if subjects were open to wearing hearing aids. If subjects answered "no" to this question, they were thanked for their participation in the research. The purpose of the study was to examine the impact of the hearing aid on listeners who were willing to "improve their hearing" with assistive devices. If subjects had indicated no desire to wear a hearing aid, they would probably not be typical of clients presenting themselves for consideration of hearing aids. However, if subjects answered "yes" to this question, it was felt that they would be typical of clients presenting themselves for consideration for using a hearing aid and then the following two scenarios occurred in random order. (1) A small In-The-Ear (ITE) hearing aid was placed in a subject's ear. Subjects were provided with a mirror for inspection. Sample hearings aids were selected from an Audiology Clinic and were not custom fit for individual subjects. Listeners were required to respond to the following questions: Would you wear this type of hearing aid if you knew that it would help improve your hearing? Why or why not? (2) A more visible Behind-The-Ear (BTE) hearing aid was placed behind the subjects' ear using stock earmolds. Subjects were provided with a mirror for inspection. Listeners were required to respond to the following questions: Would you wear this type of hearing aid if you knew that it would help improve your hearing? Why or why not?

Responses were coded as positive, negative, or neutral. The qualitative responses were first coded by the author using a positive (favorable), negative (unfavorable), or neutral (ambiguous or uncertain) response system. Positive responses included: yes, because it would help me, I would have a better quality of life, I think I would have more freedom, I really like to hear things clearly, etc. Negative responses indicated that the listeners were not responding favorably such as: no, I just don't think I would need it; It really wasn't that bad; It would need to be a lot worse before I would need a hearing aid; I would rather die than wear that; It's too big, etc. Responses were coded as neutral if the subjects' responses were ambiguous, uncertain, or nonpreferential including; e.g., I don't know what I would do, I hope I never have to decide, Maybe yes and maybe no, I don't really know what I would do, I can't decide, etc. In addition to the author's response coding system, a panel of 10 judges (7 graduate students and 3 hearing-impaired consumers) were provided with a random sample of 100 responses and asked to code the responses as positive (favorable), negative (unfavorable), or neutral (ambiguous or uncertain) using their own guidelines. No training or definitions were provided. The mean percentage of agreement was determined between the judges and the author's categorizations and resulted in 93% agreement for positive response categories, 89% for negative response categories, and 77% for neutral response categories.

Results

The analyses examined the differences between the 100 subjects' responses during the filtered and unfiltered conditions. One point was assigned for each correct response for the content questions resulting in a range of scores from 0 (no correct responses) to 10 (correct responses for the five questions after each tape). The group mean score for correct responses to the content questions was 9.9 (standard deviation = 0.3) in the unfiltered condition for the 100 subjects. The group mean score for correct responses to the five content questions was 7.6 (standard deviation = 1.3) in the filtered condition. A t-test between the filtered and unfiltered means for all 100 subjects revealed a significant difference (t(198) = 19.22; p [is greater than] .001). As expected, the filtered condition was more difficult for listeners to understand. During the unfiltered condition, no subjects indicated they would wear hearing aids, 99 subjects indicated they would not wear hearing aids, and I subject was unsure. During the filtered condition, a significant number of listeners (82) indicated they would wear hearing aids to improve their hearing (X2(2) 26.5; p [is less than] .001). Only 13 listeners indicated they would not wear hearing aids and 5 listeners were unsure. This suggests that university students realized the necessity of maintaining good listening skills through the use of wearing a hearing aid after the simulated hearing loss condition.

It was also found that of those listeners who indicated they would wear hearing aids, 88% (72) indicated they would wear the ITE hearing aid, 9% (7) indicated they would not wear the ITE hearing aid, and 4% (3) provided neutral or ambiguous responses. With regard to the preferences for the larger, more visible BTE hearing aid, 72% (59) subjects indicated they would wear the BTE hearing aid, 26% (21) indicated they would not wear the BTE hearing aid, while 2% (2) provided neutral or ambiguous responses. It was also found that of those who chose not to wear either the ITE and BTE hearing aids, 69% mentioned visibility and size as important, while 53% indicated perceived stigma and cosmetics.

These results suggest that a significant number of listeners (82%) recognized the necessity of using hearing aids. The data also suggest that 25% of the listeners would not be willing to wear the BTE hearing aid after listening to filtered speech and observing themselves wearing a hearing aid. Although 3 out of 4 listeners could easily see the benefits of amplification in improving or maintaining communication, 25% of the listeners were biased against wearing hearing aids because of the perceived stigma and/or visibility.

Implications

Speech and hearing professionals can offer informational counseling about hearing aids and hearing loss. However, additional counseling and guidance for these listeners may require the assistance of rehabilitation counselors, social workers, or psychologists. Clients may need improved hearing aid orientation sessions. Clients and their families listen to filtered speech samples simulating various degrees of hearing loss to gain a better understanding of the effects of hearing loss. Counselors may need to explain in greater detail the advantages of hearing aids to these "cosmetically or stigma sensitive" individuals. The impact of their decisions on their quality of life in maintaining good communication and social skills may be compromised. Counselors may need to spend additional time with these individuals providing them with techniques to cope and adjust to initial negative impressions by listeners. Clients may also need to be informed of the "Hearing Aid Effect" to be warned about potential prejudices and develop strategies in advance for dealing with these challenges. Guidance and advice about the many ways to deal with friends' and co-workers' initial impressions, perceptions about the stigma of hearing aids, fears about hearing loss, and better strategies for dealing with hearing loss are warranted for some individuals (Crowe, 1997). These sessions could include adjusting to the listening environment and eliminating unrealistic expectations for hearing aids. Some clients may think that the hearing aid will "cure" their hearing loss and they will need to learn the restrictions and limitations of the hearing aids. Counseling can also address the need of some clients to become more positively assertive. If clients are not understanding a speaker, they need to be instructed to identify themselves as someone with a hearing loss and ask that the speaker slow down their rate and speak more clearly. Counseling could also involve family members and significant others. If a client has finally "accepted" their hearing loss and the need for the hearing aid, family members need to be educated about the disorder. They could be instructed about the effects of a hearing loss by simply providing them with ear plugs for about 30 minutes during a session. Although they have only experienced the loss of hearing acuity and not speech perception, they begin to understand and develop empathy for the family member. Clients can also itemize the difficult listening situations (parties, social events, with children, etc.) and then each situation could be dealt with by looking for alternative solutions to enhancing the listening environment.

References

American National Standards Institute (1989). Specifications for audiometers. New York: ANSI.

American Speech Language Hearing Association (1990). Guidelines for screening for hearing impairments and middle ear disorders. ASHA, 32, (Supplement 2), 17-24.

Blood, G. W., Blood, I. M., & Danhauer, J. L. (1977). The "hearing aid effect." Hearing Instruments. 28, 12.

Blood, G. W., Blood, I. M., & Danhauer, J. L. (1978). Listeners' impressions of normal-hearing and hearing-impaired children. Journal of Communication Disorders. 11, 513-518.

Blood, I. M., & Blood, G. W. (1982). Classroom teachers' impressions of hearing-impaired and deaf children. Perceptual and Motor Skills. 54, 877-878.

Blood, I. M., & Blood, G. W. (1983). School-age children's reactions to deaf and hearing-impaired. Perceptual and Motor Skills. 57, 373-374.

Crowe, T. A. (Ed.) (1997). Applications of counseling in speech-language pathology and audiology. Baltimore: Williams & Wilkins.

Danhauer, J. L., Blood, I. M., Blood, G. W., & Gomez, N. L. (1980). Professional and lay observers impressions of hearing-impaired preschool children. Journal of Speech and Hearing Disorders. 45, 415-422.

Dengerink, J. E., & Porter, J. B. (1984). Children's attitudes toward peers wearing hearing aids. Language Speech and Hearing Services in the Schools. 15, 204-209

Himber, C. (1989). How to survive hearing loss. Washington, DC: Gallaudet University Press.

Hull, R. H. (Ed.) (1997). Aural rehabilitation: Serving children and adults (3rd Ed.). San Diego, CA: Singular Publishing Group, Inc.

Johnson, C. E., & Danhauer, J. L. (1982). Attitudes toward severely hearing-impaired geriatrics with and without hearing aids. Australian Journal of Audiology. 4, 441-445.

Kasten, R. N. (1992). Considerations for the use and orientation to hearing aids for older adults. In R. H. Hull (Ed.), Aural rehabilitation (2nd Ed.). San Diego, CA: Singular Publishing Group.

LaFerle, K. R., & LaFerle, K. (1988). Senility and its impact on the hearing instrument delivery. Hearing Instruments, 39(2), 32-35.

Mulac, A., Danhauer, J. L., & Johnson, C. E. (1983). Young adults' and peers' attitudes towards elderly hearing aid wearers. Australian Journal of Audiology, 5, 57-62.

Rupp, R. R., Higgins, J., & Maurer, J. F. (1977). A feasibility scale for predicting hearing aid use (FSPHAU) with other individuals. Journal of the Academy of Rehabilitative Audiology. 10, 81-104.

Shimon, D. A. (1992). Coping with hearing loss and hearing aids. San Diego, CA: Singular Publishing Group, Inc.

Ingrid M. Blood, College of Health and Human Development, Pennsylvania State University, 110 Moore Building, University Park, PA 16802-3100. Email: [e-mail]