Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2020 Oct 1.
Published in final edited form as: Int J Audiol. 2019 Jul 22;58(10):651–660. doi: 10.1080/14992027.2019.1608377

Qualitative Research Methods to Investigate Communication within a Group Aural Rehabilitation Intervention

Laura Coco 1,2, Maia Ingram 2, Nicole Marrone 1
PMCID: PMC6917821  NIHMSID: NIHMS1533245  PMID: 31329481

Abstract

Objective:

Aural Rehabilitation (AR) aims to minimize negative effects of hearing loss. However, there has been limited study of the lived experience of clients receiving Aural Rehabilitation services, particularly for disparity populations. The purpose of this study is to demonstrate the use of an innovative qualitative approach to investigating communication in an AR setting among Hispanic/Latino older adult dyads.

Design:

We developed a qualitative phenomenology approach using observation methods to document and analyze how individuals experience living with acquired hearing loss within group AR. Trained observers collected systematic, detailed notes on observations of participants over the course of a 5-week community-based AR intervention. In partnership with audiologists, Community Health Workers facilitated the intervention, which focused on decreasing negative communication impacts of hearing loss for families. Audiometric data and subjective hearing disability results, using the HHIE-S Spanish version, are presented as additional context for observation outcomes.

Study Sample:

Participants were older Hispanic/Latino adults with hearing loss and their frequent communication partners (5 dyads).

Results:

Four themes related to the experience of communication emerged among dyads in the intervention: (i) emotions related to hearing loss (ii) communication dynamics, (iii) self-management of hearing loss, and (iv) hearing health advocacy.

Conclusion:

A mixed methods approach that includes group observation would contribute substantially to comprehensively evaluating group AR interventions.

Keywords: Aural rehabilitation, Adult hearing loss, Qualitative research, phenomenology

Introduction

Age-related hearing loss affects one in three Americans aged 60 and older (Goman & Lin, 2016), and is characterized by progressive high frequency hearing loss that often leads to communication difficulties, particularly in the presence of background noise (Pichora-Fuller & Singh, 2006). Treatment for hearing loss typically centers on the fitting of assistive listening devices such as hearing aids, although the majority of those who could benefit are not using amplification (National Academies of Sciences, Engineering, and Medicine, 2016). In addition, hearing health care disparities contribute to low use of amplification among ethnic/racial minorities, including Hispanic/Latino adults (Nieman et al., 2016). Evidence shows the use of hearing aids can improve client outcomes, including speech understanding and quality of life (Bainbridge & Wallhagen, 2014; Kitterick & Ferguson, 2018). However, even with the assistance of devices, individuals can continue to experience communication difficulties leading to ongoing limitations in their ability to fully participate in daily activities (Gatehouse et al., 2003). Given the complexities of adapting to adult onset hearing loss, there is increased focus on aural rehabilitation (AR) to increase an individual or family’s ability to manage the effects on communication and quality of life (Hickson et al., 2013; Grenness et al., 2014; Laplante-Lévesque et al., 2012; Abrams et al., 2002).

The major components of AR include counseling, sensory management, auditory training and instruction, with the goals of minimizing the negative psychosocial effects of hearing loss, improving its self-management, and increasing the efficacy of assistive technology (Boothroyd, 2007). Specific techniques may involve hearing aid orientation, speech reading training, and/or counseling-based education (Boothroyd, 2007). AR programs may vary in length, mode of delivery (i.e. online vs. in-person), and may be group-based or one-on-one. There are many documented benefits of group AR, including improvements in quality of life (Abrams et al., 2002; Chisolm et al., 2007; Preminger & Yoo, 2010), increased use of communication strategies (Chisolm et al., 2004), and improvements in self-perceived hearing handicap (Thorén et al., 2014). Positive long-term improvements in well-being and communication have also been measured (Hickson et al., 2007; Öberg, 2017). However, as the authors of two recent systematic reviews on AR point out, certain methodological limitations across studies have resulted in a gap in our understanding of the mechanistic causes leading individuals to benefit from AR interventions (Hawkins, 2005; Michaud & Duchesne, 2017). For example, the use of different quantitative outcome measures across studies has prevented us from drawing generalized conclusions. In addition, the use of questionnaires with a composite score may fail to identify the multidimensional nature of AR and its impact on psychosocial outcomes (Preminger, 2007; Preminger & Yoo, 2010).

Qualitative data is particularly lacking among populations who are at risk for experiencing barriers in access to hearing health care, including rural communities (Coco et al., 2018; Hay-McCutcheon et al., 2018) and Hispanic/Latino populations (Nieman et al., 2016). An individual’s environment, including the barriers they face, impacts how they experience health care. A contextually-appropriate qualitative study may help contribute to an in-depth understanding of health problems in disparity populations (Stewart et al., 2008). A mixed methods approach that includes qualitative data may help characterize participants seeking hearing health education and management, contextualize their individual experiences within an AR group intervention, and ultimately, contribute to a more holistic understanding of why individuals do or do not benefit from AR. In this study, we introduce a qualitative approach to investigating communication in a group AR setting, with a focus on methods to characterize and contextualize participant experiences in a rural population of predominately Hispanic/Latino adults.

Qualitative methods have been increasingly utilized in audiology research (Knudsen et al., 2012). For example, through qualitative interview, we have gained an improved understanding of clients’ perspectives on hearing aids (Linssen et al., 2013), how couples experience hearing loss (Kelly-Campbell & Plexico, 2012), and how intervention options are chosen between clients and providers (Laplante-Lévesque et al., 2010). However, we still lack qualitative data on the client perspective of AR. The current study helps fill this gap in the literature with a phenomenological study of communication in a community-based group AR setting. The focus is on the lived experience of Hispanic/Latino older adults with hearing loss and their communication partners during their participation in a community-based AR group.

Phenomenology is a qualitative research methodology to investigate the meaning and experience of a complex phenomenon, in our study, communication. The World Health Organization provides a biopsychosocial framework for health conditions, including hearing health (Danermark et al., 2010; Davis et al., 2016). From a biopsychosocial perspective, communication has social, cultural, personal, and physiological aspects. The phenomenological approach to qualitative inquiry will allow for the study of these multiple inter-relationships, for example between perceived severity of hearing loss, cultural attitudes, personal advocacy, communication environments, and interpersonal relationships.

Phenomenological study seeks to describe a circumstance or experience from the perspective of the person who is living it. Rather than testing causal relationships, phenomenological study describes the subjective or lived experience (Flood, 2010). Phenomenology may be particularly relevant to the study of AR, where individuals may not initially acknowledge their hearing loss or how it affects their ability to communicate or understand its impact on their quality of life (Barker et al., 2017). Although age-related hearing loss is common, it develops gradually over time, and the associated communication and psychosocial impacts may not be immediately evident. An individual’s experience with acquired hearing loss can vary widely, and may include adaptations such as avoidance and denial (Wallhagen, 2009), as well as empowerment and resilience (Shih, 2004). Phenomenology has been a methodology for illuminating the experiential aspects of disability (Martiny, 2015), illness and adaptation (Carel, 2011). One way to analyze qualitative data is through the use of vignettes, or brief illustrations of synthesized data. Vignettes are used in phenomenological research, such as to illustrate a participant’s experience of a health issue or intervention (Jackson et al., 2015; Lowcock et al., 2017).

Methods

Participants

We focused on adults with hearing loss 50 years and older and their frequent communication partners (e.g. a spouse, friend, or caretaker). Table 1 provides information on participant characteristics. Participants were enrolled in a clinical trial of the intervention Oyendo Bien, or “Hearing Well” in English (ClinicalTrials.gov, ). Individuals were recruited for participation in the Oyendo Bien study by local Community Health Workers via word-of-mouth, radio advertisements, flyers, a press release to the local newspaper, and community hearing screenings conducted by audiologists. At least one of the two participants in an enrolled dyad were required to have an audiometrically confirmed hearing loss. All participants signed an informed consent document prior to the study procedures, and the study was approved by the Institutional Review Board at The University of Arizona. The Oyendo Bien intervention was described in a pilot study in Marrone et al. (2017).

Table 1.

Participant characteristics for analyzed dyads from the Oyendo Bien trial.

Dyad Relationship Pure Tone Average1 (dB HL)
 Hearing Handicap Inventory for the Elderly– Screening2 (HHIE-S) Current hearing aid user
Left Right
1 - Friends 25 25 9 No
35 37 15 No
2 - Spouses 38 60 1 No
47 53 0 No
3 - Spouses 12 8 3 No
20 20 23 No
4 - Spouses 87 68 35 No
45 37 8 No
5 - Friends 83 55 31 No
38 50 40 No
Open in a new tab
1

High frequency emphasis Pure Tone Average of 1k, 2k, and 4k Hz.

2

Participants’ baseline scores from the Hearing Handicap Inventory- Screening Spanish version (Lichtenstein & Hazuda, 1998).

Group AR Program: Oyendo Bien

Oyendo Bien is a counseling-based group AR intervention that focuses on minimizing participation restrictions and improving communication. The intervention curriculum was a Spanish-language, Mexican American cultural adaptation of an ongoing University-based intervention (Marrone & Harris 2012), based on the theoretical frameworks of social cognitive theory (Bandura, 2004; Smith & West, 2006), Behavioral Change Taxonomy (Michie et al., 2013), and motivational interviewing technique (Rollnick & Miller, 1995). Curriculum topics are presented in Table 2. Participants attended one- to two-hour sessions once per week over the course of five weeks. Participants had not previously attended AR sessions, and were not current users of hearing aids or assistive devices. Each week during the AR intervention, all participants wore assistive listening headsets that were connected to the facilitator’s microphone.

Table 2.

Descriptions of main themes identified from observation data.

Theme Description
Emotions Expressing feelings about communicating with hearing loss
Communication Dynamics Reporting interpersonal interactions affected by hearing loss
Self-management Reporting efforts to take responsibility for one’s own hearing health
Hearing Health Advocacy Reporting efforts to teach others about: hearing loss, pursuing care, using strategies for effective communication
Open in a new tab

Weekly sessions were delivered at a community gathering center. Facilitators were trained local Community Health Workers, individuals who share cultural characteristics with the community they serve and are experienced in delivering health education (Balcazar et al., 2011; Rosenthal et al., 2011). The Community Health Workers had experience in community-based health promotion and had undergone trainings specific to the Oyendo Bien curriculum, as well as general to hearing health education (Sánchez et al., 2017).

Phenomenology Approach: Observations

The study of the phenomenology of communication was undertaken here using detailed observation and documentation of participant behavior and dialogue (Musante & Dewalt, 2010). There are unique advantages to participant observation, including the ability to observe nonverbal behaviors and interactions between participants (Schmuck, 1997). In addition, unlike other data collection methods, participant observation may minimize response bias, or the tendency for a participant to be influenced by social norms or stigma when data is self-reported (Bradburn et al., 1979).

Procedures and Data Collection

As part of their enrollment in the Oyendo Bien study, each participant received an audiometric evaluation and was counseled on their results by one of the bilingual audiologists collaborating with the research project. Each participant completed the Hearing Handicap Inventory for the Elderly- Screening (HHIE-S) Spanish version, a commonly used quality of life measure that focuses on the social and emotional impacts of hearing loss (Lichtenstein & Hazuda, 1998). The HHIE-S asks individuals to consider themselves interacting in hypothetical real-life scenarios and indicate if their hearing problem negatively affects them.

Members of the research team worked closely with the class facilitators in a Community-Based Participatory Research (CBPR) framework (Marrone et al., 2017) that guided an acceptable observation design. The CBPR approach involved collaboration on ideas and decision-making power between researchers and representatives from the community (Wallerstein & Duran 2006). The literature recommends observers familiarize themselves with the community under study, including with cultural norms to help minimize investigator bias (Marshall & Batten, 2004). In the case of Oyendo Bien, the participatory nature of the study facilitated reciprocal learning between the local Community Health Workers and the academic partners, thus minimizing our concern for investigator bias (Ingram et al., 2016).

Community partner members of the research team reported that participants may not feel comfortable with audio and/or video recordings of the AR intervention. Therefore, data collection involved written observation notes of the participants’ comments and interactions. All observations notes were made by bilingual observers who came from a mix of cultural backgrounds, some of whom were Mexican-American and heritage speakers of Spanish. Notes were written in both Spanish and English, based on the choice of the observer. Observers were audiology doctoral students, research audiologists, and public health scientists with experience in AR and training in qualitative data collection. At least two observers were present at each session to write observation notes. The observers sat in a visible, yet non-intrusive location, typically near the back of the room.

Observation notes were constructed using a sensitizing framework that focused on interactions, reactions to educational information, and how dyads described their communication over the course of the five sessions (Patton, 1990). In the first sessions, the observer sought to determine the major communication challenges and then intentionally document reference to those issues over the 5-week period.

Analysis

The phenomenological approach involves a process through which the researcher first seeks to describe a phenomenon, in our case the participant experience of communication with hearing loss within an AR intervention. The second step involves identifying converging points or themes across the individual perspectives. Finally, the researcher reflects upon or interprets the meaning of these data, which can then be applied to the research question (Flood, 2010; Sadala & Adorno, 2002).

For analysis, we selected the first five dyads (10 participants) who attended all five Oyendo Bien sessions. The literature recommends sample sizes of between 5 and 25 participants (Creswell, 1998, p. 64). Our sample size of ten was large enough to demonstrate a breadth of experience, and led to the development of four themes that were common among all participants. The first and second author reviewed and coded the data separately to identify themes focusing specifically on communication. In the second step, the same two authors came to consensus by comparing codes within themes. Discrepancies in coding were discussed between the two authors and resolved them using a consensus process (Teufel-Shone et al., 2006). In a final step, they interpreted findings through additional discussion with the third, senior author. During the coding stage, observation notes were kept in their original language (Spanish or English). Themes were developed in English through a consensus process between all three authors for the purpose of disseminating our results in an English journal publication.

As part of the analysis, we synthesized the observation notes into vignettes. In previous literature, vignettes have been used to accommodate and provide structure to qualitative data (Jackson et al., 2015). In the current study, vignettes were used to capture the progression of experience of communication over the course of the five AR sessions. This approach also allowed for more specific contextual analysis of how communication between partners evolved as they discussed their experience of hearing loss, and learned constructive strategies to address and improve communication.

Results

Participant Demographics.

Among the five dyads, three were spouses, and two were friends. The median age of the ten participants was 73 years (range: 66 – 86 years). Hearing eligibility criteria was not restrictive, and therefore the study population was diverse in terms of the type and configuration of their hearing loss. However, at baseline, most participants had hearing loss that was representative of individuals with age-related hearing loss: bilateral high-frequency sensorineural hearing loss. Across all 10 participants, the average baseline self-assessment of subjective hearing disability (HHIE-S score) was 16.50 (SD = 14.80), with scores ranging from 0 (no disability) to 40 (severe disability). Three out of five dyads had similar individual HHIE-S scores, falling within the same disability severity category as one another. However, in two out of five dyads, partners had HHIE-S scores that did not align with each other. In one dyad, the partners’ HHIE-S scores differed by 20 points, and in another dyad, the partners’ scores differed by 27 points. In addition, individual subjective self-reported hearing disability did not always align with audiometric hearing test results. For example, one participant had a moderately severe to profound hearing loss and reported no subjective hearing disability, while another participant had a less severe audiometric hearing loss, and reported a higher (worse) self-report of disability according to the HHIE-S.

Observations.

Analysis of observation data revealed four converging themes related to communication and hearing loss: 1) emotions, 2) communication dynamics, 3) self-management strategies, and 4) steps toward hearing health advocacy. Refer to Table 2 for a description of each theme and Table 3 for a summary of key observations that fit within each theme across the five AR sessions In the first session, participants commented on negative emotions that they felt when hearing loss-related miscommunications happened (e.g. frustration, anger, sadness). As the sessions progressed, comments centered around improving self-management of hearing loss, including efforts to manage their own hearing loss (seeking hearing health care; talking to family members about communication strategies). The theme of hearing health advocacy was primarily noted in the 3rd and 4th sessions. Participants commented that they shared the information they learned in the intervention with individuals who were not participating in the group, including family members and others in their community. In addition, participants reported they planned to share information about how to prevent noise-induced hearing loss with younger individuals in the community. Participants also reported they talked to others about how to communicate with them more effectively.

Table 3.

Themes identified within observation notes across five sessions from the Oyendo Bien group AR program.

Group AR Session Themes from Qualitative Observations
Emotions Communication Dynamics Self-Management Hearing Health Advocacy
SESSION 1:
Building blocks of communication; communication strategies		 • embarrassed
• angry
• frustrated
• annoyed
• ignored		 • disagreement
• misunderstandings
• miscommunications
• poor communication
• denial		 • questions about etiology of hearing loss
• questions about hearing loss and dizziness
SESSION 2:
Auditory physiology; communication strategies 		• sad • trying communication strategies
• discussed how to improve communication
• misunderstanding
• reluctant to use communication strategies
• understood words with context		 • questions about etiology of hearing loss
• questions about hearing loss & home remedies
• questioning how to hear better
• shared communication needs with spouse
• questions about ear anatomy		 • talked about hearing loss with others
SESSION 3:
Emotions and communication breakdowns		 • hopeful
• feeling bad at misunderstandings
• sad/upset
• overwhelmed
• too old to pay attention
• isolated		 • using communication strategies
• communication breakdowns with family members		 • more self-aware about own hearing loss
• questions about hearing aids and ear anatomy
• teaching son how to communicate
• plans to care for ears
• awareness of talking louder as compensation for hearing loss		 • teaching others
• talking about hearing loss with family
• growing awareness of hearing loss in others
SESSION 4:
Hearing aids and assistive devices, noise-related hearing loss		 • depressed
• less angry spending time together		 • positive use of communication strategies
• not using communication strategies
• improved patience with communication		 • asking family members to use communication strategies
• considering hearing aids
• teaching extended family how to communicate
• questions about assistive technology and amplification		 • shared experiences with other family members with hearing loss
• advocated for hearing health among others
SESSION 5:
Hearing protection, self-advocacy for individuals with hearing loss		 • awareness
• understanding
• more patience
• less frustrated
• not expressing anger		 • use of communication strategies • will buy amplified phone
• recognizes own hearing loss
• questions about hearing aids
• plans to talk to doctor about hearing
• avoiding loud places where communication is difficult		 • recommended to others with hearing loss that they adopt communication strategies
Open in a new tab

Below we present three vignettes derived from observation notes as illustrative examples of the four converging themes. Although all five vignettes encompassed the themes, the included vignettes were representative of the breadth of communication experience over the course of the AR group. Notable is the difference in how communication difficulties are reported between members of the dyad, as compared to the severity of self-reported hearing disability on the standardized measures (Table 1).

Vignette A (Dyad A1/A2):

The first dyad are two female friends in their late 60s. Observation notes revealed strong emotions and self-reflections from both participants regarding communication. Both women expressed feelings of frustration regarding hearing loss, and uncertainty regarding rehabilitation options. At the first session, the woman (A1) explained she wants communication to improve within her family, and her friend (A2) talked about wanting to avoid misunderstandings when talking in in a group of people. Both women used the word “desesperante” (frustrating) in a shared way to describe hearing loss-related communication breakdowns. The woman (A1) shared that her husband would become annoyed with her when she couldn’t understand him due to her hearing loss. She also mentioned that she didn’t know what she would do about her hearing loss, and shared that her grandmother had used hearing aids, but found them unhelpful and uncomfortable.

Analysis of the observation notes revealed that the two women appeared to grow in their awareness of hearing loss across the five sessions. They began to share what they knew among other family members and friends. The women attended as friends but their discussion often focused on their communication with family members. Both women discussed what they learned in the sessions with their husbands, who were not present in the intervention. The woman (A1) said she thinks her husband also has hearing loss, and she used some communication strategies with him this week. The woman’s friend (A2) mentioned that she also talked to her husband about what she learned in the sessions, and said that she thinks he, too, is recognizing his own hearing loss. Both women asked questions related to hearing aids, medical questions related to hearing loss, and questions about noise induced hearing loss. The woman (A1) told her child not to use cotton swabs in their ear canals based on what she learned in the class. At the final session, the observer noted that the woman (A1) shared she does not quite feel ready to get a hearing aid, but decided to buy an amplified telephone, and will continue to use the communication strategies she learned in the sessions.

Vignette B (Dyad B1/B2):

The dyad are a married couple their late 60s. According to their baseline hearing test, the husband (B1) had a moderately-severe sensorineural hearing loss, and the wife (B2) had a moderate hearing loss, yet both individuals had no hearing handicap (HHIE-S = 1 and 0, respectively). At the first session, the observers noted the couple disagreed about the source of their communication difficulties. The wife attributed her frustrations to her husband’s hearing loss, yet her husband denied having a hearing problem. Over the first few sessions, the husband maintained that he was too old to learn how to communicate better. As the sessions progressed, the observers noted changes in the dyad’s interactions and comments regarding emotions, communication, self-management, and advocacy.

Analysis of observation notes revealed that the couple grew in their awareness of hearing loss. The husband began to report that he was using communication strategies, and shared that indeed, he and his wife often talk to each other from across the room. He asked that his wife not walk away from him as they are talking. Both husband and wife asked questions about causes of hearing loss and amplification, and the husband noticed his friends read his lips, possibly signifying they have a hearing loss. At the final session, the dyad shared a story about working in a loud environment and that this may have led to hearing loss. They stated that they will teach people who work in loud places about hearing protection. At the final session, observation notes revealed efforts to practice better communication. For example, the couple reported leaving a loud party due to concerns about potential hearing damage.

Vignette C (Dyad C1/C2):

The participants are spouses; the husband is in his mid-80s and the wife is in her early 70s. Both had at least a mild high-frequency sensorineural hearing loss, yet the couple differed in their baseline self-reported disability. The husband (C1) had an HHIE-S score of 3, and his wife (C2) had an HHIE-S score of 23. At the first session, observation notes documented that the dyad disagreed regarding the husband’s hearing status. The husband stated that he hears fine, yet the wife insisted that he has hearing loss. Observers also noted that both members of the dyad reported misunderstandings, frustration, and yelling due to communication breakdowns. Throughout the next few sessions, the husband was initially reluctant, but reported he later began practicing communication strategies at home. The observers documented that his wife appeared optimistic when talking to the group about her use of communication strategies. Observation notes reveal that the husband began to learn how to communicate better based on what he was learning in the AR sessions by the fourth session. The wife shared examples of successful communication throughout the past week. Analysis of the observation notes revealed, as the sessions progressed, both participants increased their positive communication interactions and appeared less frustrated with each other while communicating, when compared with the first session.

Discussion

The current study demonstrates a phenomenological approach to explore the lived experiences of individuals with hearing loss within a group AR setting. The data in the observations revealed variations in the subjective experience of communication with hearing loss within an AR intervention, highlighting the importance of qualitative study. Most of the research to date has relied on quantitative methods to evaluate individuals’ perception of their hearing loss or the impact of an AR intervention. As a result, our understanding of individuals’ experiences has been guided and limited to the specific content of each standardized questionnaire. This has led to a perhaps limited understanding of AR, and the exclusion of considerations such as cultural relevance, and the experience of communication partners versus individuals.

Phenomenology of Communication with Hearing Loss

Using a phenomenological approach, we explored aspects of the lived experience of an individual with hearing loss. Four main themes described the data:

Emotions.

In this study, participants reported negative emotions associated with communication due to hearing loss at the first AR session, including denial, embarrassment, and anger. As the sessions progressed, there was less commentary on negative emotions. Rather, participants reported more positive emotions associated with their experience with communication and hearing loss, including feeling hopeful, more patient, and less frustrated. These qualitative findings help provide context to evidence in the literature, including that older adults with hearing loss have been shown to perform poorer on tests of physical and mental functioning, and report lower overall quality of life (Chia et al., 2007). Quality of life impacts in adults with age-related hearing loss can include emotional and behavioral reactions, such as anger, embarrassment, loneliness, and lower self-esteem and denial (Ciorba et al., 2012; Dalton et al., 2003).

Communication Dynamics.

All of the dyads in our study reported experiencing miscommunications and misunderstandings in their daily lives, either with each other or among other family members and friends. As the sessions progressed, participants commented that miscommunications were fewer, and they reported implementing communication strategies. The phenomenological approach also allowed us to explore the role and experience of communication partners, and how communication was discussed between them within the context of group AR. For example, in this study, dyads initially disagreed about the cause of their communication breakdowns. As the AR sessions progressed, the dyads observed increased their awareness of hearing loss-related communication breakdowns, and employed communication strategies they learned in the class, which they felt improved their communication. Current findings are relevant to the growing body of literature on the role of the communication partner in the field of audiological enablement/rehabilitation (Manchaiah et al., 2012; Barker et al., 2017).

Self-management.

Our data revealed incidences of self-management of hearing loss as early as session two. Participants began asking questions about the cause of hearing loss and asking about previously held beliefs surrounding myths related to hearing loss. At the final session, many participants made plans for future steps to take action regarding their hearing loss. Among the observed dyads, these included plans to use communication strategies outside of the intervention, to acquire assistive listening devices, and to talk to their doctor about their hearing loss. These examples of self-management are especially promising given the resource constraints previously identified in this community (Ingram et al., 2016).

Self-management of a chronic disability is considered crucial for independence and positive quality of life (Rijken et al., 2008; Convery et al., 2018). The Chronic Care Model is a framework that describes the crucial components of the health care system that are needed to support an individual’s chronic disease care. Research using the Chronic Care Model has shown that self-management is essential for improving health outcomes for chronic conditions (Bodenheimer, 2013; Convery et al., 2018). Few standardized tools exist to measure hearing loss self-management (Convery et al., 2018). However, results of the current study suggest that tools that target the domain of self-management may be relevant to the field of AR.

Hearing health advocacy.

According to observation notes, evidence of hearing health advocacy emerged near the end of the group AR program. Participants reported that they had begun noticing hearing loss among other individuals in their community and talked to them about how they could address hearing health too, including through the use of communication strategies. Advocacy is not a commonly reported outcome in AR interventions, yet our results indicate it may play a role in an individual’s hearing loss rehabilitation journey. In addition, the role of advocacy may be different across communities. Individuals in areas that lack formal health care services may rely more heavily on peer-to-peer support. Therefore, a measure of an individual’s self-advocacy may be particularly important in areas that lack local resources for hearing health care.

Study Methodology in AR Research

This study demonstrated a methodological approach that revealed information about an individual’s hearing loss experience that may not otherwise be measured on a standardized questionnaire. Research has shown that certain factors can affect how participants respond on interview or standardized questionnaires. For example, if the term ‘disability’ is used, it may be off-putting to individuals who consider hearing loss to carry a stigma, or have not yet accepted their sensory deficit, yet experience hearing loss-related communication difficulties (Wallhagen, 2009). Additionally, some individuals may feel reluctant to self-report on their disability to those in positions of authority to avoid disapproval, or maintain a favorable self-presentation, a concept known as social desirability bias (King & Bruner, 2000). Finally, there are some issues unique to cross-cultural adaptations of questionnaires. The literacy level, approach to language translation, and format of the research questionnaire are factors that can affect an individual’s reporting of data (Heine et al., 2002; Bernal et al., 1997; Colina, 2008).

In the current study, observations revealed that all dyads experienced hearing loss-related communication challenges across documented levels of hearing levels. For example, participants B1 and B2 had no self-reported hearing disability according to the HHIE-S, yet the observations revealed that both participants described experiencing hearing loss-related communication breakdowns at home. These findings highlight the complexity of data collection in AR. One singular measure may not fully capture the participant’s experience of communication with hearing loss. Historically, social and health scientists have recognized qualitative participant observation as a valuable tool to minimize methodological challenges inherent in interview and other self-report methods (Bernard, 1998). Qualitative methods allowed documentation of participant behaviors in more naturalistic environment, with the hope that participants are responding to the group intervention authentically, thus minimizing, issues such as stigma or social desirability bias (Pryce et al., 2016). The integration of a phenomenological study of communication within an AR intervention demonstrates the feasibility and potential benefit of utilizing mixed methods to contextualize outcomes of an AR group intervention.

The use of phenomenological study may be of particular relevance here, given our study community, which experiences disparities in access to hearing health care. Our study community is rural, has limited local resources for hearing health care, and is predominately Hispanic/Latino, a group that has low use of hearing health care in the US (Ingram et al., 2016; Nieman et al., 2016). A person’s environment, including barriers they encounter to accessing health care, or aspects of their culture, can impact their experience. Phenomenology is a method to observe how participants respond in their own way, and from within their own environment without imposing assumptions a priori about their lived experience. Using this method allowed the researchers to gain an in-depth understanding of the participants’ perspectives on their own communication and health (Collingridge & Gantt, 2014). The use of qualitative methods is increasing in aural rehabilitation research, yet data among disparity populations is currently lacking.

Combining qualitative and quantitative methods in a mixed methods design is recommended to improve understanding of intervention science (Palinkas, 2011). A mixed methods study that integrates observation data with a client’s response to standardized questionnaires may lead to a more comprehensive understanding of an individual’s experience within an AR intervention over time. Such analysis is planned as part of future research with the full Oyendo Bien clinical trial sample.

Ultimately, results of mixed methods studies may improve a clinician’s understanding of the context and nuance of a client’s experience in an AR program. In addition, standardized questionnaires used in research are also often used as clinical referral tools and may reflect a clinician’s probe used to start the conversation with clients around hearing loss. Based on our study, clinicians may consider reframing questions to probe the experience of communication rather than subjective hearing loss per se, to bring less stigma to conversations on hearing health among older adults. Failing to identify hearing loss can lead to delayed treatment. Further, the risk of inaccurately or inadequately reporting the impact of aural rehabilitation on client outcomes could result in lack of public or policy-level support. For example, help-seeking is known to be related to a person’s perceived benefit from a potential intervention (Saunders et al., 2012).

Methodological considerations and future directions

There are methodological considerations involved in conducting a phenomenological study with observational methods. Data collection may involve field notes, video recordings, photographs, recording participant dialogue, among others (Patton, 1990). In this study, trained observers summarized and documented participant dialogue and interactions as a written note. While there are benefits to recording and transcribing a participant’s own words, including the use of precise language to clarify meaning if needed, limitations also exist. Contextual information, including environmental cues and nonverbal data, are not always captured in audio or even video recordings, yet are available in written observation notes (Sutton & Austin 2015). In addition, recordings introduce issues related to privacy, ethics, and power differentials between researchers and participants. Our study showed that written observation notes are both detailed and relatively unobtrusive, and can be useful in settings where other forms of observation data collection are unavailable or inappropriate. Future studies may need to consider the advantages and disadvantages within their community contexts when choosing to utilize the methodology presented in this study with or without audio recording and transcription. The current study’s methodology is accessible and adaptable, and therefore may be transferable to studying AR among different populations, and in different contexts. Future investigations should explore if the themes identified in this study are specific to aspects of this study (i.e. the community under study, the intervention content, the group format) or if they are representative of AR interventions in general.

Conclusion

The experience of communication among older Hispanic/Latinos with acquired hearing loss in an Aural Rehabilitation group surrounded emotions related to hearing loss, communication dynamics, self-management of hearing loss, and hearing health advocacy. Through our analysis of participant observation, we found that all five dyads experienced hearing loss-related communication difficulty, yet some participants did not report this difficulty in a baseline subjective questionnaire of hearing handicap. The results of this study can inform researchers and clinicians on the planning and development of mixed methods research. Specifically, outcome measures with emphasis on individual disability may not fully capture the varied and diverse lived experiences encompassing communication in dyads.

Figure 1.

Figure 1.

Open in a new tab

Average left ear pure-tone thresholds for 10 participants. Solid lines indicate one standard deviation.

Figure 2.

Figure 2.

Open in a new tab

Average right ear pure-tone thresholds for 10 participants. Solid lines indicate one standard deviation.

Acknowledgements

The authors thank Conchita Somoza, Cecilia Navarro, and Alicia Sander, Promotoras de Salud, and Rosie Piper for their partnership in this project. The authors also gratefully acknowledge Aileen Wong, Au.D., Tanyha Zepeda, Anette Real-Arrayga, Clemente Morales, Adriana Sanchez, Daisey Sánchez, and Stephanie Adamovich, Ph.D. for their contributions in data collection and management. Research in this publication was supported by the National Institute on Deafness and Other Communication Disorders of the National Institutes of Health under Award Number R33 DC013681 (PI: N.M.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Portions of this research were presented at the annual meeting of the American Auditory Society in Scottsdale, AZ on March 2, 2018.

References

  1. Abrams HB, Chisolm T, & McArdle R (2002). A cost utility analysis of adult group audiologic rehabilitation: Are the benefits worth the cost? Journal of Rehabilitation Research and Development, 39(5), 549–558. [PubMed] [Google Scholar]
  2. Bainbridge KE, & Wallhagen MI (2014). Hearing loss in an aging American population: extent, impact, and management. Annual Review of Public Health, 35, 139–152. [DOI] [PubMed] [Google Scholar]
  3. Balcazar H, Rosenthal EL, Brownstein JN, Rush CH, Matos S, & Hernandez L (2011). Community health workers can be a public health force for change in the United States: Three actions for a new paradigm. American Journal of Public Health, 101(12), 2199–2203. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Bandura A (2004). Health promotion by social cognitive means. Health Education Behavior, 31(2), 143–164. [DOI] [PubMed] [Google Scholar]
  5. Barker AB, Leighton P, & Ferguson MA (2017). Coping together with hearing loss: a qualitative meta-synthesis of the psychosocial experiences of people with hearing loss and their communication partners. International Journal of Audiology, 56(5), 297–305. [DOI] [PubMed] [Google Scholar]
  6. Bernal H, Wooley S, & Schensul JJ (1997). The challenge of using Likert-type scales with low-literate ethnic populations. Nursing Research, 46(3), 179–181. [DOI] [PubMed] [Google Scholar]
  7. Bernard HR (1998). Research methods in anthropology: Qualitative and quantitative approaches (6th ed). Walnut Creek, CA: AltaMira Press. [Google Scholar]
  8. Bodenheimer T Interventions to improve chronic illness care: evaluating their effectiveness. Disease Management. 2003;6(2):63–71 [DOI] [PubMed] [Google Scholar]
  9. Boothroyd A (2007). Adult aural rehabilitation: What is it and does it work?. Trends in Amplification, 11(2), 63–71. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Bradburn NM, Sudman S, Blair E, Locander W, Miles C, Singer E, & Stocking C (1979). Improving interview method and questionnaire design: Response effects to threatening questions in survey research. San Francisco, CA: Jossey-Bass. [Google Scholar]
  11. Caballero AE (2011). Understanding the Hispanic/Latino patient. The American Journal of Medicine, 124(10), S10–S15. [DOI] [PubMed] [Google Scholar]
  12. Carel H (2011). Phenomenology and its application in medicine. Theoretical Medicine and Bioethics, 32(1), 33–46. [DOI] [PubMed] [Google Scholar]
  13. Chia EM, Wang JJ, Rochtchina E, Cumming RR, Newall P, & Mitchell P (2007). Hearing impairment and health-related quality of life: the Blue Mountains Hearing Study. Ear and Hearing, 28(2), 187–195. [DOI] [PubMed] [Google Scholar]
  14. Chisolm TH, Abrams HB, & McArdle R (2004). Short-and long-term outcomes of adult audiological rehabilitation. Ear and Hearing, 25(5), 464–477. [DOI] [PubMed] [Google Scholar]
  15. Chisolm TH, Johnson CE, Danhauer JL, Portz LJ , Abrams HB, Lesner S, McCarthy PA, Newman CW (2007) A systematic review of health-related quality of life and hearing aids: final report of the American Academy of Audiology Task Force on the Health-Related Quality of Life Benefits of Amplification in Adults. Journal of the American Academy of Audiology, 18(2):151–183. [DOI] [PubMed] [Google Scholar]
  16. Ciorba A, Bianchini C, Pelucchi S, & Pastore A (2012). The impact of hearing loss on the quality of life of elderly adults. Clinical Interventions in Aging, 7, 159–163. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Colina S (2008). Translation quality evaluation: Empirical evidence for a functionalist approach. The Translator, 14(1), 97–134. [Google Scholar]
  18. Convery E, Meyer C, Keidser G, & Hickson L (2018). Assessing hearing loss self-management in older adults. International Journal of Audiology, 57(4), 313–320. [DOI] [PubMed] [Google Scholar]
  19. Collingridge DS, & Gantt EE (2008). The quality of qualitative research. American Journal of Medical Quality, 23(5), 389–395. [DOI] [PubMed] [Google Scholar]
  20. Creswell John (1998). Qualitative inquiry and research design: Choosing among five traditions. Thousand Oaks, CA: Sage. [Google Scholar]
  21. Dalton DS, Cruickshanks KJ, Klein BE, Klein R, Wiley TL, & Nondahl DM (2003). The impact of hearing loss on quality of life in older adults. The Gerontologist, 43(5), 661–668. [DOI] [PubMed] [Google Scholar]
  22. Davis A, McMahon CM, Pichora-Fuller KM, Russ S, Lin F, Olusanya BO, Chadha S & Tremblay KL (2016). Aging and hearing health: the life-course approach. The Gerontologist, 56(S2), 256–267. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Danermark B, Cieza A, Gimigliano F, Granberg S, Hickson L, Kramer SE, McPherson B, Möller C, Russo I, Strömgren JP and Stucki G (2010). International classification of functioning, disability, and health core sets for hearing loss: a discussion paper and invitation. International Journal of Audiology, 49(4), 256–262. [DOI] [PubMed] [Google Scholar]
  24. DeWalt K & DeWalt BR (2002). Participant observation: a guide for fieldworkers. Walnut Creek, CA: AltaMira Press. [Google Scholar]
  25. Flood A (2010). Understanding phenomenology. Nurse Researcher, 17(2), 7–15. [DOI] [PubMed] [Google Scholar]
  26. Gatehouse S, Naylor G, & Elberling C (2003). Benefits from hearing aids in relation to the interaction between the user and the environment. International Journal of Audiology, 42, S77–S85. [DOI] [PubMed] [Google Scholar]
  27. Goman AM, & Lin FR (2016). Prevalence of hearing loss by severity in the United States. American Journal of Public Health, 106(10), 1820–1822. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Grenness C, Hickson L, Laplante-Lévesque A, & Davidson B (2014). Patient-centred care: A review for rehabilitative audiologists. International Journal of Audiology, 53, S60–S67. [DOI] [PubMed] [Google Scholar]
  29. Hawkins DB (2005). Effectiveness of counseling-based adult group aural rehabilitation programs: A systematic review of the evidence. Journal of the American Academy of Audiology, 16, 485–493. [DOI] [PubMed] [Google Scholar]
  30. Heine SJ, Lehman DR, Peng K, & Greenholtz J (2002). What’s wrong with cross-cultural comparisons of subjective Likert scales?: The reference-group effect. Journal of Personality and Social Psychology, 82(6), 903. [PubMed] [Google Scholar]
  31. Hickson L, Worrall L, & Scarinci N (2007). A randomized controlled trial evaluating the active communication education program for older people with hearing impairment. Ear and Hearing, 28, 212–230. doi:0196/0202/07/2802-0212/0 [DOI] [PubMed] [Google Scholar]
  32. Hickson L, Laplante-Lévesque A, & Wong L (2013). Evidence-based practice in audiology: Rehabilitation options for adults with hearing impairment. American Journal of Audiology, 22(2), 329–331. [DOI] [PubMed] [Google Scholar]
  33. Ingram M, Marrone N, Sánchez DT, Sander A, Navarro C, de Zapien JG, Colina S, Harris F (2016). Addressing hearing health care disparities among older adults in a U.S.-Mexico border community. Frontiers in Public Health, 4, 169. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Jackson M, Harrison P, Swinburn B, & Lawrence M (2015). Using a qualitative vignette to explore a complex public health issue. Qualitative Health Research, 25(10), 1395–1409. [DOI] [PubMed] [Google Scholar]
  35. Kelly-Campbell R, & Plexico L (2012). Couples’ experiences of living with hearing impairment. Asia Pacific Journal of Speech, Language and Hearing, 15(2), 145–161. [Google Scholar]
  36. King MF, & Bruner GC (2000). Social desirability bias: A neglected aspect of validity testing. Psychology and Marketing, 17(2), 79–103. [Google Scholar]
  37. Kitterick P & Ferguson M (2018). Hearing aids and health-related quality of life in adults with hearing loss. JAMA: Journal of the American Medical Association, 319(21), 2225–2226. [DOI] [PubMed] [Google Scholar]
  38. Knudsen LV, Laplante-Levesque A, Jones L, Preminger JE, Nielsen C, Lunner T, Hickson L, Naylor G and Kramer SE (2012). Conducting qualitative research in audiology: A tutorial. International Journal of Audiology, 51(2), 83–92. [DOI] [PubMed] [Google Scholar]
  39. Laplante-Lévesque A, Hickson L, & Worrall L (2010). A qualitative study of shared decision making in rehabilitative audiology. Journal of the Academy of Rehabilitative Audiology, 43, 27–43. [Google Scholar]
  40. Laplante-Lévesque A, Hickson L, & Worrall L (2012). What makes adults with hearing impairment take up hearing aids or communication programs and achieve successful outcomes? Ear and Hearing, 33(1), 79–93. [DOI] [PubMed] [Google Scholar]
  41. Lichtenstein MJ, & Hazuda HP (1998). Cross-cultural adaptation of the Hearing Handicap Inventory for the Elderly-Screening Version (HHIE-S) for use with Spanish-speaking Mexican Americans. Journal of the American Geriatrics Society, 46(4), 492–498. [DOI] [PubMed] [Google Scholar]
  42. Linssen AM, Joore MA, Minten RK, van Leeuwen YD, & Anteunis LJ (2013). Qualitative interviews on the beliefs and feelings of adults towards their ownership, but non-use of hearing aids. International Journal of Audiology, 52(10), 670–677. [DOI] [PubMed] [Google Scholar]
  43. Lowcock D, Warwick-Booth L, Grewal P, & Underwood S (2017). Using vignettes in qualitative research: Examples from health promotion research. SAGE Research Methods Cases. doi: 10.4135/9781526403711 [DOI] [Google Scholar]
  44. Malmberg M, Lunner T, Kähäri K, & Andersson G (2017). Evaluating the short-term and long-term effects of an internet-based aural rehabilitation programme for hearing aid users in general clinical practice: a randomised controlled trial. BMJ Open, 7(5), e013047. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Manchaiah VK, Stephens D, Zhao F, & Kramer SE (2012). The role of communication partners in the audiological enablement/rehabilitation of a person with hearing impairment: an overview. Audiological Medicine, 10(1), 21–30. [Google Scholar]
  46. Marrone N, & Harris F (2012). A multifaceted living well approach to the management of hearing loss with adults and their frequent communication partners. SIG 7 Perspectives on Aural Rehabilitation and its Instrumentation, 19(1), 5–14. [Google Scholar]
  47. Marrone N, Ingram M, Somoza M, Jacob DS, Sánchez A, Adamovich S, & Harris FP (2017). Interventional audiology to address hearing health care disparities: Oyendo Bien pilot study. Seminars in Hearing, 38(2), 198–211. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Marshall A, & Batten S (2004). Researching across cultures: Issues of ethics and power. Forum: Qualitative Social Research, 5(3), 39. [Google Scholar]
  49. Michaud HN, & Duchesne L (2017). Aural rehabilitation for older adults with hearing loss: impacts on quality of life—a systematic review of randomized controlled trials. Journal of the American Academy of Audiology, 28(7), 596–609. [DOI] [PubMed] [Google Scholar]
  50. Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles MP, Cane J & Wood CE (2013). The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Annals of Behavioral Medicine, 46(1), 81–95. [DOI] [PubMed] [Google Scholar]
  51. Musante K, & DeWalt BR (2010). Participant observation: A guide for fieldworkers. Rowman Altamira. [Google Scholar]
  52. National Academies of Sciences, Engineering, and Medicine. (2016). Hearing Health Care for Adults: Priorities for Improving Access and Affordability. Blazer D, Liverman C, Domnitz S, eds. Washington, D.C.: National Academies Press. [PubMed] [Google Scholar]
  53. Nieman CL, Marrone N, Szanton SL, Thorpe RJ Jr, & Lin FR (2016). Racial/ethnic and socioeconomic disparities in hearing health care among older Americans. Journal of Aging and Health, 28(1), 68–94. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Öberg M (2017) A multicentre study evaluating the effects of the Swedish ACE programme, International Journal of Audiology, 56:11, 876–886. [DOI] [PubMed] [Google Scholar]
  55. Palinkas LA, Aarons GA, Horwitz S, Chamberlain P, Hurlburt M, & Landsverk J (2011). Mixed method designs in implementation research. Administration and Policy in Mental Health and Mental Health Services Research, 38(1), 44–53. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Patton MQ (1990). Qualitative Evaluation and Research Methods (2nd ed.). Newbury Park, CA: SAGE Publications, Inc. [Google Scholar]
  57. Pichora-Fuller MK, & Singh G (2006). Effects of age on auditory and cognitive processing: implications for hearing aid fitting and audiologic rehabilitation. Trends in Amplification, 10(1), 29–59. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Preminger J (2007). Issues associated with the measurement of psychosocial benefits of group audiologic rehabilitation programs. Trends in Amplification, 11(2), 113–123. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Preminger JE, & Yoo JK (2010). Do group audiologic rehabilitation activities influence psychosocial outcomes?. American Journal of Audiology, 19(2), 109–125. [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Pryce H, Hall A, Laplante-Lévesque A, & Clark E (2016). A qualitative investigation of decision making during help-seeking for adult hearing loss. International Journal of Audiology, 55(11), 658–665. [DOI] [PubMed] [Google Scholar]
  61. Rijken M, Jones M Heijmans M, Dixon A. (2008) Supporting self-management In Nolte E, & McKee M (Eds.). Caring for people with chronic conditions: a health system perspective. (pp. 116–142). Maidenhead: McGraw-Hill Education. [Google Scholar]
  62. Rollnick S & Miller WR (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23(4), 325–334. [DOI] [PubMed] [Google Scholar]
  63. Rosenthal EL, Wiggins N, Ingram M, Mayfield-Johnson S, & De Zapien JG (2011). Community health workers then and now: An overview of national studies aimed at defining the field. The Journal of Ambulatory Care Management, 34, 247–259. [DOI] [PubMed] [Google Scholar]
  64. Sadala MLA, & Adorno RDCF (2002). Phenomenology as a method to investigate the experience lived: a perspective from Husserl and Merleau Ponty’s thought. Journal of Advanced Nursing, 37(3), 282–293. [DOI] [PubMed] [Google Scholar]
  65. Sánchez D, Adamovich S, Ingram M, Harris FP, De Zapien J, Sánchez A, Colina S & Marrone N (2017). The potential in preparing community health workers to address hearing loss. Journal of the American Academy of Audiology, 28(6), 562–574. [DOI] [PMC free article] [PubMed] [Google Scholar]
  66. Saunders GH, Chisolm TH, & Wallhagen MI (2012). Older adults and hearing help-seeking behaviors. American Journal of Audiology, 21(2), 331–337. [DOI] [PubMed] [Google Scholar]
  67. Schmuck RA (1997). Schmuck, Richard A., Practical Action Research for Change. Arlington Heights, IL: Skylight Training and Publishing. [Google Scholar]
  68. Schensul SL, Schensul JJ, & LeCompte MD (1999). Essential ethnographic methods: Observations, interviews, and questionnaires (Vol. 2). Walnut Creek, CA: Altamira. [Google Scholar]
  69. Shih M (2004). Positive stigma: Examining resilience and empowerment in overcoming stigma. The Annals of the American Academy of Political and Social Science, 591(1), 175–185. [Google Scholar]
  70. Smith SL, & West RL (2006). The application of self-efficacy principles to audiologic rehabilitation: A tutorial. American Journal of Audiology, 15(1), 46–56. [DOI] [PubMed] [Google Scholar]
  71. Sutton J, & Austin Z (2015). Qualitative research: data collection, analysis, and management. The Canadian Journal of Hospital Pharmacy, 68(3), 226. [DOI] [PMC free article] [PubMed] [Google Scholar]
  72. Teufel-Shone NI, Siyuja T, Watahomigie HJ, & Irwin S (2006). Community-based 584 participatory research: Conducting a formative assessment of factors that influence youth 585 wellness in the Hualapai community. American Journal of Public Health, 96(9), 1623–1628. [DOI] [PMC free article] [PubMed] [Google Scholar]
  73. Wallhagen MI (2009). The stigma of hearing loss. The Gerontologist, 50(1), 66–75. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES