Abstract
Older adults with hearing loss face many challenges in day to day communication. Although hearing aids come with many technologies and features, the use and benefit are still not as expected. The possible non-audiological factors that can influence the benefit from hearing aid remain uncertain. The present study focuses on assessing the influence of attitude towards loss of hearing and personality on the perceived hearing aid benefit in older adults. Attitude towards loss of hearing questionnaire (ALHQ) and Eysenck Personality Inventory (EPI) were administered on 42 older adults having mild to moderately-severe sensorineural hearing loss, who were naïve users of hearing aid. Two months later, International Outcome Inventory—Hearing Aids (IOI-HA) scores and the number of hours of hearing aid use through data logging of hearing aid were noted. Individuals with extrovert trait of personality and with acceptance towards hearing loss had higher number of hours of hearing aid usage and higher IOI-HA scores. Discussion: The individuals with extrovert personality, positive attitude towards hearing loss tends to depend on the amplification device for better communication and involve themselves more in social interaction. Poor acceptance and negative social or emotional reaction towards hearing loss can have a greater impact on hearing aid use and benefit. The present study highlights the importance of assessing the attitude and personality in older adults with hearing loss before fitting the hearing aid. These measures can be focussed during counselling about the realistic expectation of outcome from the hearing aid.
Keywords: Attitude, Personality, Hearing aid outcome, Older adults
Introduction
Background
Presbycusis is the hearing loss that is associated with aging process and this affects communication. Majority of those with presbycusis fail to accept that they have a hearing loss [1]. Hearing aids are the most effective form of help for presbycusis; the individuals seeking help from hearing aids are in a small proportion [2]. Various studies have shown that although the hearing aids have been benefitting them, very few use the hearing aids [3, 4]. Most important to note in the elderly population is that the hearing aid benefit also depends on non-auditory factors such as age, lifestyle, cognitive impairment, dexterity, personality, and attitude towards hearing loss [5–7].
Kochkin surveyed 250 hearing aid dispensing audiologists and indicated that various factors like cosmetic appearance, vanity, or the stigma associated with hearing aids are the reasons for the non-purchase of hearing aids [8]. Stephens et al. found that in a community survey of 50–65-year-old individuals reporting hearing loss, 50% of them were reluctant to use hearing aids when suggested for the use of it [9]. Even if the hearing aid is obtained, there is considerable reluctance to use it as it is perceived as a less desirable facet of getting older [1, 2, 5].
The hearing aid use is strongly associated with the acceptance of hearing problems [10]. It was found that older adults tend to use a hearing aid when they accepted the social and emotional handicap associated with age-related hearing loss. Also, individuals who wanted help from an audiologist were reported of greater emotional distress [9]. A study by Hickson et al. revealed that 64% of the participants with negative attitudes used hearing aid very occasionally whereas, 41% with positive attitudes continued using their hearing aid regularly and benefited the most from hearing aids [11]. However, the individuals who used hearing aids occasionally may also reflect an aspect of learning, which may not necessarily be due to a negative attitude [12].
An individual's personality is indicated by his or her characteristic style of thinking, feeling, and behaving. Personality of an individual can also affect the hearing aid acceptance. But relatively little research has been carried out on factors such as personality and its effect on hearing aid outcome measures [13, 14]. Cox et al. found that extroverted persons benefitted more in understanding speech with hearing aid, whereas individuals with an external locus of control i.e., those who feel that other people control good things in life, had problems adjusting with hearing aids. Several studies have found that neuroticism, extroversion/introversion, locus of control contribute to the handicap measures to a great extent, even though the degree of hearing loss was not the same among the participants [7, 13, 15, 16].
The primary focus of the present audio logical rehabilitation is outcome-based approaches. Research has shown that many audiologists do not use the outcome measures to validate the hearing aid fitting in their clinical practice [17]. The present study aims to focus on the effect of the personality of older adults and their attitude towards loss of hearing on hearing aid outcome measures. Exploring the non-audiological factors can help an audiologist know the association between these factors and the benefit of hearing aid. This would in turn throw some light on the strategies that can be implemented during programming and counselling. Attitude towards Loss of Hearing Questionnaire (ALHQ), developed by Brooks, is a questionnaire that is used to identify the factors associated with the lifestyle of a person [10]. Unlike fewer studies where the responses obtained were from simple questions related to the attitude of the person, the present study focus on using ALHQ which comprises of subscales to assess the social and emotional impact of hearing loss, acceptance/adjustment to hearing loss, perceived support from significant others, hearing aid stigma and awareness of hearing loss. Also, in the present study, the Eysenck Personality Inventory (EPI) developed by Eysenck and Eysenck, which assesses the personality of an individual [18], is used to get information on the personality type of the elderly hearing aid user.
Aim
To study the influence of attitude towards loss of hearing and personality on hearing aid outcome in older adults with hearing loss.
Objectives
To study the association between attitude towards loss of hearing and hearing aid outcome in older adults with hearing loss.
To study the association between personality and hearing aid outcome in older adults with hearing loss.
The null hypotheses framed were, there is no significant effect of attitude towards loss of hearing on hearing aid outcome, and there is no significant effect of personality on hearing aid outcome in older adults with hearing loss.
Methods
To investigate the objectives, the present study involved assessing attitude towards loss of hearing and personality in older adults before fitting the hearing aid. Following these, the participants had to use prescribed hearing aids. The hearing aid outcome measures were assessed after a span of two months of hearing aid use. It was ensured that the ‘Ethical guidelines for bio-behavioural research involving human subjects, 2009′were followed [19].
Participants
A total of 42 individuals in the age range from 60 to 78 years, with a mean age of 71.6 years, were recruited as participants in the study. Of them, only 34 completed the 2 months follow-up. The data of eight individuals were excluded as they did not return for follow-up testing. Among the considered 34 participant’s data, 19 were males, and 15 were females. The participants were diagnosed to have mild to moderately severe sensorineural hearing loss and had bilateral A type tympanogram. Individuals with any neurological, medical, or otological history—other than hearing loss, were not included in the study. All the participants were naïve hearing aid users and were fitted with four channel digital behind the ear (BTE) hearing aids. The participants were selected using a purposive sampling technique. The purpose and nature of the study were explained to each participant, and written informed consent was taken before the commencement of the testing. It was also ensured that the participants had normal vision or had corrected vision. The participants were native of Kannada language and studied Kannada and English as subjects, at least till 10th Standard or equivalent.
Procedure
The participants were included for the study after a detailed case history followed by otoscopic and ENT examination to rule out the presence of wax and any middle ear pathologies. All the participants were subjected to audio logical testing, which included pure-tone audiometry, speech audiometry, and immittance evaluation to ensure that they satisfied the participant inclusion criteria.
After the purchase of the prescribed hearing aid/s, the hearing aids were programmed. For this, the digital BTE hearing aid was connected to the personal computer, with respective software with NOAH platform (version 4.6), using HiPro (version 2) and programming cable. The hearing aids were programmed using NAL-NL1 fitting formula with the acclimatization level set to ‘Non-experienced’ or ‘Naïve’ hearing aid users. The hearing aids were programmed to omni directional mode with noise cancellation being activated, and the data logging feature was enabled. All the participants were fitted with a custom ear mould coupled to the hearing aid. Detailed counselling about use, care, adjustment to hearing aid, and maintenance of hearing aids were done.
In the follow-up session after two months of hearing aid use, information on the number of hours of hearing aid use was collected from the participant. The data logging feature of the hearing aid allowed the audiologist to verify the number of hours of use of hearing aids.
Three questionnaires were used in the study. The Attitude towards Loss of Hearing Questionnaire (ALHQ), developed by Brooks and later refined and standardized for clinical use by Saunders and Cienkowski [16], was used to assess the attitude towards hearing loss. The Eysenck Personality Inventory (EPI), given by Eysenck and Eysenck, was used to assess the personality of the participants [18]. These two questionnaires were administered before the fitting of hearing aid. The international outcome inventory for hearing aids (IOI-HA) was used to assess the outcome from the hearing aid which was administered after two months of hearing aid use.
ALHQ
The ALHQ questionnaire consists of 24 questions. It has 5 subscales that evaluate factors such as social and emotional impact of hearing loss (question numbers 19, 2, 11, 12, 17, 21, 20, 16,3,18), lack of acceptance to hearing loss and adjustment to hearing loss (question numbers 8, 22, 10, 5, 18,16), perceived absence of support from significant others (question numbers 6, 14, 13, 15), hearing aid stigma (question numbers 4, 1, 9, 7), and awareness of hearing loss (question numbers 23, 3, 24, 21). Some questions appear in more than one domain or subscale. The questionnaire has a response in the form of ‘yes’ or ‘no.’
Scoring of ALHQ
Two points are awarded for a ‘yes’ response, and zero point is awarded for a ‘no’ response. The questionnaire is framed in such a way that if one gets a higher score on the questionnaire, the individual has an acceptance of his/her hearing loss and its impact on his/her social life.
EPI
The Eysenck Personality Inventory (EPI), given by Eysenck and Eysenck, was used to assess the personality of the participants [18]. The four types/dimensions of personality considered in EPI [18] and their characteristics are:
(1) Extroversion- An individual who is characterized by an out-going, candid, enthusiastic, optimistic, and accommodating nature. And also one who adapts easily to any situation quickly forms attachments and setting aside possible misgivings. Also, he/she will be characterized by careless confidence in unknown situations.
(2) Introversion- An individual who is characterized to have a hesitant nature, reflective, retiring nature, shrinks from objects, and also tends to be independent. The person might not necessarily be unhappy or pessimistic, are always slightly on the defensive side, and prefers to hide behind mistrustful scrutiny.
(3) Neuroticism- An individual who is characterized to have predisposed experiences of negative emotions such as anger, embarrassment, and guilt. They usually tend to be hostile and anxious and cope relatively poorly with stressful situations. They also have low self-confidence and are likely to blame others for their problems.
(4) Emotional stability- An individual who is characterized to have a mental state of calmness and composure. Such individuals cope well with stress.
Scoring of EPI
The inventory has response in the form of ‘yes–no’. There are a total of 57 items, out of which 24 items are for extroversion/introversion (E) scale and 24 items for neuroticism/emotional stability (N) scale and 9 items for lie (L) detection scale. The Table 1 represents the classification of EPI scores into subscales.
Table 1.
Classification of EPI scores into subscales
| Subscale | EPI Score | Dimension |
|---|---|---|
| E | 16 and above | Extroversion |
| E | 7 and below | Introversion |
| L | 8 and above | Not valid |
| N | 17 and above | Neuroticism |
| N | 6 and below | Emotionally well adjusted |
E extroversion, L lie scale, N neuroticism
If the participant’s score on E scale were from 7 to 16, then he/she would be termed as an ambivert [20]. In this study, participants having an L score of 8 and above were excluded.
IOI-HA
The International Outcome Inventory—Hearing Aid (IOI-HA) in Kannada [21, 22] was administered to assess the hearing aid outcome. The IOI-HA comprises of seven questions on a five-point rating scale,
Scoring of IOI-HA
The total score is 35, as it has seven questions and each question uses a five-point rating. A higher score on IOI-HA reflects better hearing aid outcome. The questions cover seven domains, which include hearing aid use, benefit, residual activity limitations, satisfaction, residual participation restrictions, impact on others, and quality of life.
After 2 months of hearing aid use, the participant was followed up. During the follow-up, the information about the number of hours of hearing aid use (HA-Use) was collected using the data logging feature of the hearing aid. The IOI-HA was administered during the follow-up.
Results
The data obtained from the questionnaires were tabulated for statistical analyses using the SPSS software (SPSS 20). The study aimed to determine if there is any association between attitude towards loss of hearing and personality type with hearing aid outcome measures.
The data were subjected to statistical analysis. Descriptive statistics of the data are including the mean, median, standard deviation, and range measures were obtained for the obtained data (Table 2).
Table 2.
Mean, median, standard deviation (SD) and range of the scores for ALHQ, EPI, IOI-HA and HA Use
| Questionnaire/Measures | Mean | Median | SD | Range | |
|---|---|---|---|---|---|
| ALHQ | SE (Max. score: 14) | 12 | 11 | 2.0 | 10–14 |
| LAA (Max score: 10) | 9 | 8 | 1.0 | 8–10 | |
| PAS (Max. score: 7) | 4 | 5 | 1.3 | 3–6 | |
| HAS (Max. score: 6) | 3 | 3 | 0.6 | 2–4 | |
| AHL (Max. score: 7) | 6 | 6 | 0.9 | 5–7 | |
| EPI | E subscale (Max. score: 24) | 12.25 | 12.5 | 5.98 | 4–20 |
| N subscale (Max. score: 24) | 13 | 13 | 2.23 | 4–20 | |
|
L subscale (Max. score: 9) |
8.3 | 8 | 0.5 | 8–9 | |
| IOI–HA (Max. score 35) | 28.02 | 29 | 4.04 | 20–34 | |
| HA Use (no. of hours per day) | 4.34 | 3.8 | 2 | 1.8–8 | |
ALHQ attitude towards loss of hearing, EPI eyesenck personality inventory, IOI-HA International Outcome Inventory–Hearing Aids in Kannada, SE social and emotional impact of hearing loss, LAA lack of acceptance to hearing loss and adjustment to hearing loss, PAS perceived absence of support from significant others, HAS hearing aid stigma, and AHL awareness of hearing loss, E extroversion, N neuroticism, L lie
In order to test for normal distribution of the dependent variables, that is the hearing aid use and outcome from hearing aid as measured using IOI-HA, Shapiro–Wilk Test was performed. The results showed that the data from variables were not normally distributed (p < 0.05).
Attitude towards hearing loss and Hearing aid outcome measures: The responses obtained from the ALHQ were subjected to statistical analysis. Spearman correlation was administered to find out the relationship between ALHQ overall scores with IOI-HA, and also ALHQ overall score with HA-Use. The results of the Spearman correlation suggested that there was a strong positive correlation between ALHQ and IOI-HA (r = 0.7, p < 0.05); and ALHQ and HA-Use (r = 0.77, p < 0.05).
-
Subscales of ALHQ and Hearing aid Outcome measures: The same statistical measure Spearman correlation was also used to find the relationship between ALHQ subscales with IOI-HA, and HA-Use. Table 3 represents the results obtained for the subscales of ALHQ with IOI-HA and HA-Use.
The results show that there is a significant positive correlation for social and emotional impact of hearing loss with IOI-HA and hearing aid use. There was a significant negative correlation between lack of acceptance of hearing loss and adjustment to hearing loss with IOI-HA and hearing aid use. This indicates that the individual who is aware of or accepts his/her hearing loss feels the need for a hearing aid, and hence will perceive more benefit from the hearing aids. However, there was no significant correlation obtained for hearing aid stigma, perceived absence of support from significant others with IOI-HA and HA-Use.
-
Personality and Hearing aid outcome measures: The responses of the 34 participants to EPI were were divided into extrovert or introverts. The data consisted of 15 extrovert individuals, 10 were introvert, and three were ambivert. Data of six individuals were excluded as the responses of items on L scale (lie scale) crossed a score of eight. Based on N scale, the individuals were divided as neuroticism or emotionally stable. Hence data consisted of 11 individuals with neuroticism who also had introvert personality trait, and six individuals were emotionally stable. The remaining 11 individuals were neither neurotic nor emotionally stable.
Figures 1 and 2 represent the mean and standard deviation (SD) of overall scores on IOI-HA and mean and standard deviation (SD) of the number of hours of HA-Use among participants having different types of personality.
The Spearman correlation test was administered to find the relationship between personality type and overall IOI-HA score, also with personality type and HA-Use. Table 4 represents the results obtained for the subscales of EPI with IOI-HA and HA-Use. The results of the Spearman correlation suggested that there was a strong positive correlation between personality type and IOI-HA (r = 0.71, p < 0.05) and personality type and HA Use (r = 0.794, p < 0.05).
-
Subscales of EPI and Hearing Aid Benefit: Spearman correlation coefficient was calculated for the subscales of EPI. The raw scores of E and N subscales were compared with IOI-HA and HA-Use. The results showed that there was a strong positive correlation between E subscale and IOI-HA (r = 0.79, p < 0.001) and E subscale and HA-Use (r = 0.81, p < 0.001). However, there was no significant correlation obtained for N subscale with IOI-HA (r = −0.29, p > 0.05) or with HA-Use (r = −0.25, p > 0.05).
From Fig. 2 it can be noted that the participants with extrovert personality had higher IOI-HA scores, with greater number of hours of hearing aid use. These individuals perceived more benefit from their hearing aid when compared to those with an introvert personality. Individuals with ambivert personality also had higher IOI-HA scores and higher number of hours of hearing aid use. Figures 3 and 4 represent the mean IOI- HA scores and mean HA-Use for N subscale of EPI. From Figures 3 and 4, it can be noted that the neurotic individuals showed lower IOI-HA scores and lesser number of hours of hearing aid use when compared to emotionally stable individuals. But the results do not show significant difference across means in statistical measures. The reason could be that the variation in IOI-HA scores and HA-Use were higher in these groups, which can be observed through the error bars that show one standard deviation value.
Subjective data of hearing aid use vs Datalogging feature: The subjective data of number of hours of hearing aid use were taken from every participant. Also actual hearing aid use data from data logging feature were noted to verify with subjective data. These data were subjected to statistical analysis to the organization of the results, discussion and conclusions are very disorganized in the abstract and in discussion and results, etc. at the end of the paper.compare with IOI-HA. Spearman correlation shows a strong positive correlation between HA Use and IOI-HA scores (r = 0.753, p < 0.05). This is to infer that more the use of hearing aid, better the benefit obtained from hearing aids.
Table 3.
Spearman correlation co-efficient (r) values for subscales of ALHQ with IOI-HA and HA-Use
| Subscales of ALHQ | Correlation (r) and p values |
|
|---|---|---|
| IOI-HA | HA-Use | |
| Social and emotional impact of hearing loss (SE) |
r = 0.75 p < 0.001 |
r = 0.79 p < 0.001 |
| Lack of acceptance to hearing loss and adjustment to hearing loss (LAA) |
r = −0.68 p < 0.05 |
r = −0.71 p < 0.05 |
| Perceived absence of support from significant others (PAS) |
r = 0.19 p > 0.05 |
r = 0.205 p > 0.05 |
| Hearing aid stigma (HAS) |
r = −0.21 p > 0.05 |
r = −0.29 p > 0.05 |
| Awareness of hearing loss (AHL) |
r = 0.719 p < 0.001 |
r = 0.786 p < 0.001 |
IOI-HA international outcome inventory—hearing aid in Kannada, HA-Use hearing aid use
Fig. 1.
Mean overall score on IOI-HA for participants having different traits on extroversion subscale of EPI. Error bars show one standard deviation
Fig. 2.
Mean number of hours of HA-Use per day for participants having different traits on extroversion subscale of EPI. Error bars show one standard deviation
Table 4.
Spearman correlation co-efficient (r) values for subscales of EPI with IOI-HA and HA-Use
| Correlation and p values | |||
|---|---|---|---|
| Personality Type | E subscale | N subscale | |
| IOI- HA | r = 0.71, p < 0.05 | r = 0.79, p < 0.001 | r = −0.29, p > 0.05 |
| HA Use | r = 0.794, p < 0.05 | r = 0.81, p < 0.001 | r = −0.25, p > 0.05 |
Fig. 3.
Mean IOI-HA scores for neuroticism subscale of EPI. Error bars show one standard deviation
Fig. 4.
Mean number of hours of HA-Use per day for neuroticism subscale of EPI. Error bars show one standard deviation
Discussion
The present study aimed to find out the influence of attitude towards hearing loss and personality on hearing aid outcome measures in older adults with hearing loss. The individuals who were fitted with the hearing aid should benefit from it in order to reduce the impact of hearing loss on day to day communication.
Attitude Towards Hearing Loss and Hearing Aid Benefit
Few studies which majorly concentrates on audio logical factors fail to answer the aspect of poor benefit inspite of having better speech scores or lesser degree of hearing loss. A study done by Brooks et al. showed that the amount of benefit obtained from the hearing aids is also influenced by non-audiological factors, such as age, counselling, personality, and attitude of a person [1]. The present study used ALHQ to study the attitude factors of an elderly hearing aid user. The rationale for this kind of research is that a better and multi-dimensional understanding of the non-auditory factors and its implication in the areas of counselling. Once the individual has knowledge of the expected realistic benefit, the positives, and negatives of the hearing aid, he/she can adapt accordingly. In a wider context, the hearing aid fitting starts with a counselling, that can be made more effective with these realistic expectations.
The results of the present study showed that individuals who had more acceptance of their hearing loss and who were aware of the hearing loss had better hearing aid use (more than 3.5 h per day) when compared to those who did not accept the fact that they had hearing problems (1.5 to 3 h per day). The significance of this can be correlated to distress/inadequacy about acceptance of hearing loss [9, 10]. Higher the lack of acceptance, the more the tendency of reluctancy to wear hearing aids. The present study found a lack of association between hearing aid stigma and hearing aid benefit, which is in line with the findings of a previous research [1]. The outcome measures were not associated with knowledge about the social reactions of others to difficulties in communication. The earlier cited study showed that negative reactions of significant others (family members) acted as a crucial aspect in the use of hearing aid [1].
The highlights of the present study is the use of subscales of ALHQ constituting social, emotional aspects, acceptance of hearing loss, awareness about the hearing loss, its impact on social life allows us to predict the attitude of the person and its effect on hearing aid outcome measures. The negative attitudes might not show an immediate effect soon after fitting a hearing aid; but, in a long run, might play a role [23]. Thus, the null hypothesis that states there is no association between attitude towards hearing loss and hearing aid outcome measures is rejected.
Personality and Hearing Aid Benefit
The personality differences that exist between individuals are likely to cause an impact on hearing aid outcome measures. The personal style may impact the hearing aid use and, in turn affect the perceived benefit from it [24]. From the present study, it can be noted that individuals with extrovert personality perceived a greater benefit from hearing aid when compared to introverts, which were in line with the findings of a few researchers [13, 25]. Individuals with introvert personality might possess unrealistic high expectations about the hearing aids and may react negatively when the expectations are not met [14].
Individuals who are socially active and mingle with the social crowd can be observed in extrovert personality type, use the hearing aids in several environments, and may see more improvement and is satisfied with it [26]. The present study used a more recognized personality domain that is extroversion-introversion, whereas there are other studies that have studied temperaments like idealists, artisans, etc.[14]. Although the studies showed the variations or patterns in methodological aspects, the impact of those on hearing aid benefit has yielded similar results [14, 26]. Thus, the second null hypothesis that states there is no association between personality and hearing aid outcome measures is rejected.
Conclusions
The present study focussed on evaluating the non-auditory measures like personality and attitude towards loss of hearing on hearing aid outcome measures. Personality differences and attitude towards loss of hearing have been a significant measure, especially in older adults, as suggested by many researchers. In the present study, the EPI and ALHQ were administered on 34 older adults. These measures were correlated with IOI-HA and hearing aid use, after two months of hearing aid fitting. Though it is hard to draw a cause and effect relationship with the design used in the present study, the results of the present study suggest that the personality and attitude can cause variability in hearing aid outcome measures. The personality of an individual will decide, to some extent, the acceptance of hearing loss and consistent use of hearing aid. Individuals with extrovert personality reaped better benefits when compared to individuals with an introvert personality. In addition, results of the subscale of ALHQ show that individuals who had higher social and emotional impact of hearing loss and awareness about hearing loss performed better with hearing aid. It can be inferred that individuals react differently to their hearing loss, during the intervention and an audiologist needs to look into these differences and counsel the individuals accordingly.
Funding
The authors did not approach/obtain any funding or grants for carrying out the present study.
Code Availability
Not applicable.
Compliance with Ethical Standards
Conflict of interest
Authors of the present study have no conflict of interest.
Ethical Approval
The study obtained clearance from institutional ethical board and followed ‘Ethical guidelines for bio-behavioural research involving human subjects, 2009′ [AIISH, 2009].
Informed Consent
The purpose and nature of the study were explained to each participant, and written informed consent was taken before the commencement of the testing about the use of the data for the purpose of research.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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