This study investigated the effect of rehabilitation group composition on self-perception of handicap and satisfaction with the audiologist in hearing impaired elderly. Group compositions included subjects only, subjects and a support spouse, and subjects and a support peer. Results indicated that the participation of support members made a significant difference in HHIE and ACES-E scores.
Introduction
Elderly patients present unique challenges when they undergo audiologic evaluation and rehabilitation. An individual's response to audiologic rehabilitation programs is affected by a variety of factors, including personality, general health, age and gender, financial capabilities, motivation, social activities, and reactions by family and friends (Taylor & Jurma, 1997; Garstecki & Erler, 1999; Barry & McCarthy, 2001; Barry & Barry, 2002). In short, elderly populations can face difficulties with rehabilitation programs both related and unrelated to degree of measured hearing loss. Implementing effective counseling methods into the rehabilitative process is critical to success, particularly with the elderly. It has been established that rehabilitation/counseling programs are beneficial in promoting successful use of amplification with elderly patients (Kricos & Holmes, 1996; McCarthy, 1996). Further, rehabilitation and counseling programs have been shown to be helpful in reducing self-perception of handicap (Malinoff & Weinstein, 1989). Taylor and Jurma (1999) reported that group rehabilitation programs were effective in reducing self-perceived handicap when used with the elderly. Integrating social contacts with traditional rehabilitation strategies can increase patients' personal involvement in their rehabilitation programs and motivation to seek help in dealing with their hearing loss. Such an environment provides a cooperative climate for patient growth through the assimilation and application of information regarding strategies for coping with hearing loss.
Two indicators of the relative effectiveness of group audiologic rehabilitation programs are patient perception of handicap and patient perception of audiologist effectiveness. To that end, the use of self-assessment data to document positive outcomes as a result of amplification and rehabilitation has become both a clinical practice and a research priority.
The inventory that has been used extensively in self-perceived handicap is the Hearing Handicap Inventory for the Elderly (HHIE) developed by Ventry and Weinstein (1983). The HHIE uses a self-report methodology with a series of statements probing social and emotional responses to hearing impairment using a yes/no/sometimes format. The paradigm used to measure hearing benefit and/or perceived degree of handicap in most of these studies involved administration of the HHIE on a pre- and post-hearing aid fitting/pre- and post rehabilitation program basis. Outcome is measured by comparing the degree of handicap assessed in each administration of the questionnaire. Positive outcome is defined as a reduction in self-perceived hearing handicap as a result of amplification and/or rehabilitation. The Audiologist Counseling Effectiveness Scale for the Elderly (ACES-E) developed by Taylor (1993b) is designed to assess satisfaction of elderly patients with the counseling they receive from their audiologists. The ACES-E is composed of 26 items that assess patients' perception of audiologists' counseling and service provision in the emotional and informational domains. Patients react to statements by indicating their degree of agreement using a 5-point scale anchored by (1) not at all and (5) strongly agree. The ACES-E can be used in conjunction with other indices like the HHIE to interpret patients' reactions to audiologic rehabilitation programs and to tailor treatment protocols to the needs of particular patients.
Taylor and Jurma (1999) concluded that when patients participated in rehabilitation programs involving both audiologist appointments and group sessions there was not the significant increase in HHIE scores (self-perceived handicap) that has been reported following several months of amplification use (Malinoff & Weinstein, 1989; Taylor, 1993a). Further, subjects who participated in the group sessions rated their audiologists more positively on both dimensions of ACES-E than subjects who had only audiologist appointments.
This study investigated the effect of rehabilitation group composition on self-perception of handicap and satisfaction with the audiologist in hearing impaired elderly subjects. Previous studies have indicated that group rehabilitation programs are an effective strategy for dealing with hearing loss in the elderly. While it is assumed that a supportive/group environment should facilitate rehabilitation efforts, no study has investigated the effects of group composition on perceptions of handicap and audiologist effectiveness. Three conditions of group composition were considered in this study. They included subjects only, subjects with support spouses, and subjects with support peers.
METHOD
Subjects
Sixty adults (30 males and 30 females) with sensorineural hearing loss between the ages of 63 and 81 years (M=69.4) served as subjects. All subjects had bilateral sensorineural hearing losses with pure-tone averages no better than 40 dB HL at 1000, 2000, and 4000 Hz in the better ear and a significant handicap (score> 18) as measured by the Hearing Handicap Inventory for the Elderly (Ventry & Weinstein, 1983). All subjects were native English speakers with adult onset hearing loss and were in good general health. The subjects were fitted with amplification prior to placement in a rehabilitation group. None of the subjects had experience with amplification prior to the current fitting.
The subjects were assigned to one of six rehabilitation groups: two groups of subjects only; two groups of subjects each with an accompanying spouse; and two groups of subjects each with an accompanying peer. Five males subjects and five female subjects participated in each group. Prefitting and 3-week postfitting HHIE scores, and variables such as age and degree of hearing loss were balanced across the subject groups (Table 1).
Procedure
Each of the subjects received instruction on the use of their amplification and general strategies for maximizing its use at the time of fitting. Each subject completed the HHIE and the ACES-E at the 3-week post-fitting appointment. Subjects were assigned to six rehabilitation groups of ten persons, each group composed of five males and five females. Two groups consisted of subjects only. Two groups consisted of subjects each with an accompanying spouse and the last two groups consisted of subjects each with an accompanying peer.
Subjects and support members returned for four audiologic rehabilitation sessions over the next eight weeks, each session lasting approximately 1 ½ hours. In a previous study, Taylor and Jurma (2000) interviewed elderly patients after three months of hearing aid use. Content analysis of those interviews indicated that responses reflected three general categories: (1) Technical Difficulty (adjusting the aid, insertion and removal of the aid, and physical discomfort); (2) Self Concept (hearing aid did not make them feel better about themselves and their ability to communicate); and (3) Social Effectiveness (conversations with friends and family were not entirely satisfactory, difficulty hearing in social contexts such as groups, restaurants, etc.). Based on this information, the four rehabilitation sessions were designed to address problems associated with these topics and to suggest strategies for addressing frustration from both an informational and emotional perspective. All groups participated in these discussions and activities.
During the first group session, support members (spouses and peers) were instructed to have at least three encounters per week with their assigned subjects. These encounters were to allow for discussions of progress in adapting to amplification and commentary on the quality of communication in these interactions. During each of the following sessions, accompanying spouses and peers received instruction as to how to facilitate these encounters as well as provide positive emotional and communication support. The support members were afforded the opportunity to interact with each other to discuss strategies.
The four audiologic rehabilitation sessions were scheduled between the 3-week and 3-month post-fitting appointments. When subjects returned for their 3-month follow up, they again completed the HHIE and ACES-E scales.
RESULTS
Previous research indicates that elderly hearing aid patients perceive their handicap as significantly decreased three weeks after fitting, but significantly increased from the 3-week assessment following 3 months of hearing aid use (Taylor, 1993a). Significantly higher perceptions of handicap at 3 months may indicate a realization that quality of hearing may not be as fully or adequately restored as patients had hoped and it is at this point that some new hearing aid users fail in their rehabilitation programs. This study was designed, in part, to investigate whether a program of audiologic rehabilitation could mediate and reduce this increase. Table 2 contains a summary of HHIE results for subjects after 3 months of hearing aid use. The one-way analysis of variance indicated significance for total, emotional, and situational scores (F's 2,57 = 4.45, 3.85, and 4.05 respectively, p's
Table 3 contains information pertinent to ACES-E. The one-way analysis of variance indicated significance for total, emotional, and informational components (F's = 6.75, 6.95, and 7.00 respectively, p's
DISCUSSION
Increasing participation of audiologists and speech-language pathologists in rehabilitation efforts for hearing impaired adults and the need for quality assurance in this process necessitates the documentation of the efficacy of such programs. The present study suggests that elderly patients demonstrate a reduction in perceived handicap as a result of participation in an audiologic rehabilitation program between the 3-week and 3-month post-fitting period and that reduction of perceived handicap is greater when a support person (spouse or peer) is actively involved in the process. Further, participation in such programs enhances subjects' perceptions of audiologist effectiveness in counseling. How such programs can be optimally developed and administered remains a priority.
Group rehabilitation programs provide several possibilities for complementing traditional one-on-one audiologist/patient relationships. From the audiology perspective, group programs allow the professional to provide more in-depth services to a larger number of patients. Additionally, speech-language pathologists can become involved in the provision of services. Elderly patients also gain from affiliation with others like themselves. Group counseling allows them to increase the number of their social contacts, which, in turn can increase their motivation to succeed. They can exchange information regarding both successful and unsuccessful strategies for dealing with hearing loss. Utilization of a rehabilitation partner (spouse or peer) further increases the number of social contacts and provides immediate support for the patient. Patients can interact with their support partner outside of the formal program and build on what the audiologist/speech-language pathologist has suggested as effective strategies. In this way, each patient and his/her support partner can adapt strategies to meet their individual needs.
In addition to providing information related to the effectiveness of group rehabilitation, several concrete indicators of effective group composition were discovered in this study.
Even though the differences were not statistically significant, this study's findings suggest that subjects perceived their handicap to be lower and they were more satisfied with their audiologist when peers participated in their rehabilitation program than when spouses accompanied them. Anecdotally, subjects suggested that their peers were more consistently supportive of their efforts to cope in society than their spouses. Spouses were more likely to express frustration at constantly repeating comments and adapting to their spouse's handicap than were peers. Subjects admitted that this frustration was warranted given the substantial periods of time they were around their spouses. Subjects also expressed self-consciousness about their communication effectiveness given their hearing loss. Development of programs designed to facilitate long-term communication between hearing impaired patients and spouses might be helpful. Findings from the current study indicate the importance of support partners in rehabilitation. Identification of optimal partners and the nature of their roles merit further investigation.
CONCLUSIONS
This study of group composition in audiologic rehabilitation programs yielded a number of interesting findings that may be useful to professionals who work with elderly adults with hearing impairments. Most importantly, elderly subjects demonstrate a reduction in measured handicap as a result of participation in an audiologic rehabilitation program. Participation by a third party (spouse or peer) further decreases self-perception of handicap. Elderly subjects demonstrate an increase in their perceptions of audiologist effectiveness following participation in such programs. The study supports the assumption that third parties/spouses/communication partners can provide reinforcement for patients; commentary on their progress, and suggestions for improvement and that such support can positively affect self-perception of handicap and perception of audiologist/speech-language pathologist effectiveness in the domain of aural rehabilitation.
The findings raise questions about the need for appropriate training of support partners regarding the use of positive strategies and maintenance of realistic expectations. Further research on the roles and effectiveness of third party participants in audiologic rehabilitation programs is warranted.
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Portions of this article were previously presented in a poster session at the ASHA 2002 convention.
