Adult Aural Rehabilitation Notes

OUTLINE

• Adults

• Prevalence of Hearing Loss Among Adults

• Who Is This Person?

• Where Is the Patient in the Journey?

• A Patient-Centered Approach

• The Aural Rehabilitation Plan

• Case Study: One Size Doesn’t Fit All

• Final Remarks

• Key Chapter Points

• Terms and Concepts to Remember

• Key Resources

• Appendix

Aural Rehabilitation for Adults

• The aural rehabilitation process requires the orchestration of several interventions to maximize benefits for patients and their communication partners.

• Services are affected by factors like the country/state of delivery and healthcare funding/structure.

  • In the U.S., services are largely privately paid.

  • In Scandinavia, services are more likely government-funded (Gatehouse, 2003).

• Insurance coverage for services like auditory training varies.

• Aural rehabilitation plan elements:

  • Assessment

  • Listening devices

  • Auditory and speechreading training

  • Communication strategies training

  • Counseling

  • Group interactions

  • Tinnitus management

• Chapter focuses on patients aged 17-60 who participate in family, community, and work.

• The major goal is to promote conversational fluency.

• Chapter 10 is devoted to older adults (over 60 years).

Prevalence of Hearing Loss Among Adults

• Common stereotypes suggest that adult-onset hearing loss occurs primarily in older persons.

• Individuals in their 40s and 50s increasingly experience hearing loss, in large part because of the world becoming an increasingly noisy place and increased use of earbuds and headphones.

• Longitudinal study in Beaver Dam, Wisconsin (Nash et al., 2011):

  • Prevalence of hearing loss:

    • 21-34 years: $3\%$

    • 35-44 years: $6\%$

    • 45-54 years: $11\%$

    • 55-64 years: $22\%$

• Most adults lose hearing gradually; the largest segment has mild or moderate sensorineural hearing loss.

• Thresholds for mid and high frequencies are typically poorer than those for lower frequencies (Agrawal et al., 2008).

Who Is This Person?

• Addressing "Who is my patient?" requires considering:

  • Stage of life

  • Life factors

  • Socioeconomic status

  • Race/ethnicity

  • Psychosocial well-being

  • Home, social, and vocational communication difficulties

  • Gender

  • Other hearing-related conditions (e.g., tinnitus).

Stage of Life

• Example: Lee Lieu and his son Kevin's car accident resulted in irreversible bilateral hearing losses.

• The impact of hearing loss differs due to their different life stages.

• Lee is an advertising firm owner contemplating early retirement due to communication difficulties.

• Kevin is a college junior in public relations, questioning his career path due to hearing loss.

• Life stages are age ranges where hearing loss may have different impacts.

• Table 10-1: Life Stages and the Impact of Hearing Loss

  • Young adulthood

    • Events: Develop intimate relationships, accept financial responsibility, envision future, reassess dreams.

    • Impact: Experience self-doubt about finding a life partner.

  • The thirties

    • Events: Reassess life decisions, career consolidation, modify life structures, invest in job/family/friends.

    • Impact: Hesitation about change arises.

  • Middle adulthood

    • Events: Consider mortality, note physical aging, feel the last chance to make changes, upward mobility may cease.

    • Impact: Uncertainty about goals and ability to achieve them may increase.

  • The fifties

    • Events: Children may have left home, the career may be well established, time is available to pursue leisure activities, may consider early retirement.

    • Impact: Fears of aging intensify, withdrawal from leisure activities may occur.

  • Late adulthood

    • Events: Deterioration in health/attractiveness/strength, loss of friends/family, review of life's meaning.

    • Impact: Other aging problems are intensified (e.g., loneliness), and overall sense of loss is exacerbated.

• Adults with hearing loss experience similar emotions and difficulties; however, the impact relates to their stage of life.

• Physically, cognitively, and socially, individuals at 55 differ from their 25-year-old selves, confronting different issues.

Life Factors

• By adulthood, most people have established relationships, a vocation, a personality, and a worldview.

• Life factors are conditions defining one’s life (relationships, family, vocation), socially/culturally determined, or influenced by individual or environmental qualities.

• A patient with a heart problem and an extended family may be less concerned about a mild or moderate hearing loss than someone who has been taking antidepressants and recently lost a job.

• Figure 10-4: Life factors that influence how a male patient views hearing loss

  • Concentric circles: self, home, work, recreation, and community.

  • Self: Prior to hearing loss, a person viewed themself as competent and independent.

    • Hearing loss can lead to:

      • Belief: “I can handle it.” Or a loss of self.

  • Home/Family: Kinships make one feel useful, connected, loved, and needed.

    • Hearing loss can strain these bindings; destabilize the family.

  • Work: Hearing loss may hinder interactions, causing workers to feel a loss of competitive edge, requiring extra preparation and effort.

    • The question arises on maximizing communication effectiveness at the workplace.

  • Recreation:

    • The person may become the object of subtle teasing.

  • Community: Ignorance and prejudice about disabilities may occur.

• Reactions may cause patients to withdraw from activities and companions.

• Figure 10-6: Influence of the community

  • Represented as a jigsaw puzzle rearranged by community norms.

  • Community views hearing loss as a tragedy, social problem, or medical issue.

  • Viewpoints determine support services, technologies, and expectations.

• Questions to address:

  • What kind of help do I need and where will I get it?

  • How am I to live my life as a person with hearing loss?

  • What kind of financial and technical support might I expect?

  • How am I to contribute to the world around me and live my life?

Socioeconomic Status

• Socioeconomic status is based on income, occupation, education, and dwelling type.

• Examples of how socioeconomic status affects aural rehabilitation:

  • Financial status: Determines the choice between one or two hearing aids, and the quality of healthcare available.

  • Educational history: Dictates background knowledge about ear anatomy and disorders; influences willingness to seek amplification or cochlear implant.

  • Employment status: affects access to hearing healthcare services.

Race, Ethnicity, and Culture

• Racial, ethnic, cultural, and linguistic groups have distinct customs, beliefs, and service preferences.

• Considerations for customizing aural rehabilitation programs:

  • Value of emotional expression

  • Concepts of time (clock-time vs. event-time)

  • Individualistic vs. collectivist perspectives

  • Esteem for healthcare professionals

  • Adherence to alternative healing systems

  • Experiences with economic hardship and medical care.

• ASHA (2011) identified three culturally related points:

  • Everyone has a culture shaped by communities and shared experiences.

  • Culture is dynamic; cultural norms change as people acculturate.

  • Culture is expressed through explicit and implicit variables.

• Improve rehabilitation quality by:

  • Acquiring cultural and linguistic competence.

  • Developing relationships with cultural informants.

  • Attending cultural events.

  • Learning how a patient's background influences clinical decisions.

The Deaf Culture

• Figure 10-7

• The Deaf culture has four hallmarks of any culture:

  • A shared language: American Sign Language.

  • Behavioral norms: Ways for getting someone’s attention (e.g., hand waving, tapping the person’s shoulder) and leave-taking, among others.

  • Values: Which include Deaf politics, Deaf clubs, and everyday amenities such as visual/vibrating alerting systems and captioning.

  • Traditions: Centered on face-to-face gatherings of people who are Deaf, which include Deaf alumni events, senior citizen gatherings, and religious services, and other such gatherings that are often replete with folklore, arts, songs, poetry, and joke-telling.

• Membership in the Deaf culture affects the aural rehabilitation plan.

• Members lost hearing early in life, use sign language, and see themselves as culturally/linguistically distinct.

• Membership is based on identification with Deaf people, not the degree of hearing loss.

• Services include sign interpreters who translate spoken language into sign language and vice versa.

Psychosocial Well-Being

• Relates to a person’s positive self-image and sense of social integration.

• Hearing loss affects interactions; patients may be ostracized, diminishing well-being.

• Stigmatization: Societal belief in an undesirable attribute (hearing loss) and/or characteristic (difficulty talking).

• Self-stigma: Patients adopt prejudicial views, amplifying stress, shame, low self-esteem, degraded self-image, and maladaptive behaviors.

Home, Social, and Vocational Hearing-Related Communication Difficulties

• How patients spend their time informs the aural rehabilitation plan.

• Survey by Prince Market Research (2004) on adults aged 41-60:

  • Home/Social difficulties:

    • Two-thirds reported difficulty hearing the television.

    • Three-quarters found themselves where people didn't speak loudly/clearly enough.

    • Avoided watching television with others and social gatherings.

  • Workplace/Job issues:

    • One-fourth reported affected work.

      • $67\%$ severe hearing loss

      • $42\%$ moderate hearing loss

    • Phone calls (64\%$%) and coworker conversations (61\%$%) were most impacted.

    • Fewer than $5\%$ asked for employer help.

    • One-fourth said reduced earning potential.

• Figure 10-8:

  • Conceptualize how hearing loss affects a patient’s daily life.

  • The two-ringed model represents relative time spent in different settings.

  • Audiologists ask these questions

    • Question Set 1: How big a “slice” of your day is spent at home? At work? At leisure?

    • Question Set 2: For each slice, with whom do you talk? How do you spend your time? and What sounds would you like to hear?

Gender Differences

• Figure 10-8

• If you are a woman with hearing loss:

  • You are twice as likely as a man to disclose your hearing loss (West & Konstantina, 2015).

  • You are better at offering suggestions to your conversational partners about how to enhance conversations (e.g., “My left ear has hearing loss, would you mind sitting on my right side?”) (West & Konstantina, 2015).

  • You are more comfortable with sustained eye contact, so you probably gain more benefit from the visual speech signal and from speechreading.

  • You are more likely to use hearing aids and to use them for longer periods at a time (Staehelin et al., 2011).

Vertigo

• Vertigo is a type of dizziness in which a patient inappropriately experiences a sensation of motion, such as a spinning sensation while sitting still or a tilting and swaying sensation while standing upright.

• May also experience nausea, vomiting, nystagmus, falling, faintness, and unsteadiness.

• It typically arises from a disorder of the vestibular system and may occur in the presence of normal hearing.

• When it co-occurs with hearing loss, the dual symptoms may be indicative of Ménière’s disease, acoustic neuroma, viral infection, head trauma, a fistula in the inner ear, and familial progressive vestibular-cochlear dysfunction, among other conditions.

• The audiologist may perform these diagnostic tests:

  • Audiological testing

  • Electronystagmogram and videonystagmogram (ENG and VNG) tests

  • Fakuda test

  • Auditory brainstem response testing

  • Rotator chair testing.

• Vestibular rehabilitation therapy is a type of physical therapy that is provided by an audiologist

• The team may include an otolaryngologist, a neurologist, a neuro-otologist, an internist, and/or a physical therapist.

Tinnitus

• Most tinnitus is subjective, meaning that it is a phantom sound sensation.

• A person might perceive sound in the right ear, left ear, both ears, or inside or outside of the head.

• Common descriptors:

  • Leaves rustling

  • The ocean roaring

  • Crickets chirping

  • A radio playing off-station

  • A siren blasting

  • A telephone ringing

  • A single pure tone, either low-pitched or high-pitched

• Kochkin, Tyler, and Born (2011) reported tinnitus often accompanies adult hearing loss, with about $55\%$ reporting tinnitus also reporting hearing loss.

• Most prevalent among people over 55, experienced for almost half of each day.

• Table 10-2: Data collected from 2,369 patients at the Oregon Tinnitus Clinic.

  • $40\%$ could not identify a cause.

  • Remaining etiologies fell into four categories:

    • Noise-related

    • Head and neck trauma

    • Head and neck illness

    • Other medical conditions/drugs/stress/surgery.

• Some illnesses include Ménière’s disease, acoustic neuroma, and head and neck injuries.

• Some tinnitus-inducing agents include aspirin, salicylates, quinine, aminoglycoside antibiotics, and cisplatin causing transient or chronic tinnitus.

• Diet may exacerbate tinnitus: Salt (especially in patients with high blood pressure) restricts blood vessels, raises blood pressure, and impedes blood circulation.

• Tinnitus can impair concentration, create listening difficulties because it may mask the speech signal, and disrupt sleep, and has proven to reduce the quality of life (Nondahl et al., 2007).

• Because tinnitus is often symptomatic of medical conditions other than hearing loss, a patient should see an otolaryngologist to rule out medical/surgically treatable ear pathology.

Where Is the Patient in the Journey?

• Figure 10-10

• The patient journey refers to the experiences and processes where a patient passes experiencing hearing loss and in participating in an aural rehabilitation plan.

• The term patient journey refers to the experiences and processes a patient passes through in the course of experiencing hearing loss and in participating in an aural rehabilitation plan.

• Six distinct phases:

  • Pre-awareness

  • Awareness

  • Movement

  • Diagnosis

  • Rehabilitation

  • Resolution

Pre-Awareness

• With few exceptions (e.g., family history), individuals don't anticipate hearing loss, especially before 61.

• Family/friends notice missed conversation, loud talking, high TV volume.

Awareness

• Often happens gradually; the patient may not know when the loss began.

• Alerting situations:

  • Having to ask for repetition

  • Not hearing doorbell/name

  • Missing conversations

• Other indicators:

  • Complaining about bad telephone connections

  • Not knowing sound direction

• Family remarks about coping behaviors and rationalizations.

• Patients may self-test radio volume or telephone use.

Movement

• Patients consult family physician, talk to family/friends, search the web.

• Move toward consulting a hearing healthcare professional.

• Psychological costs:

  • Acceptance of hearing problem

  • Anxiety about aging

  • Awkwardness requesting time off work

  • Worry about cost or exploitation

  • Fear of no solution

  • Embarrassment entering a hearing clinic

Diagnosis

• The audiologist identifies and quantifies hearing loss.

• An individual may expect a rapid solution.

• Anxiety may arise realizing hearing loss is here to stay.

• Concerns about profession, loss of independence, altered social status.

• Awareness and movement phases mediate the anxiety level.

• The Americans with Disabilities Act

  • As adults adjust to their hearing loss, they may take advantage of some of the provisions included in the 1990 Americans with Disabilities Act (ADA).

  • Forbids discrimination against persons with disabilities and requires that “reasonable accommodation” be made in public access, including employment and transportation.

• Table 10-3: Key Features of the Americans with Disabilities Act as It Pertains to Individuals with Hearing Loss

  • TITLE I: Guarantees equal employment opportunities.

  • TITLE II: Governmental agencies, including transportation programs, must make their programs accessible to people with hearing loss.

  • TITLE III: Public places (operated by private entities) including businesses, professional offices, and nonprofit organizations must provide communications access.

  • TITLE IV: Telephone companies provide relay services throughout the US free of charge

Rehabilitation

• Not always discrete; movement to/from the adjacent phases might occur.

Resolution

• Also referred to as “postclinical or adjustment”.

• Patients adjust to ramifications and either accept remaining issues or move back to the rehabilitation phase.

• Not static; patients may cycle back and forth.

A Patient-Centered Approach

• Focuses on care that respects/responds to patient preferences and needs, guided by their values.

• Patients are treated with dignity, building on their strengths and promoting control.

• In a patient-centered program, patients may articulate their concerns, discuss their specific difficulties, and work to devise solutions to their hearing-related difficulties.

• Contrasts with biomedical and sales orientations.

  • Biomedical: Reduces hearing loss to the biological dimension of diagnosis and then focuses on the organs and mechanisms of hearing rather than the person.

  • Sales orientation: Emphasizes persuasion to use aural rehabilitation services or listening devices with a great offer.

• A patient-centered philosophic orientation states that certain aural rehabilitation offerings may be more appropriate for some patients than others and available services can be adjusted to meet a patient’s need.

The Aural Rehabilitation Plan

• Figure 10-11

• Components of a patient-centered aural rehabilitation plan:

  • Assessment

  • Informational counseling

  • Development of a plan

  • Implementation

  • Assessment of outcome

  • Follow-up

Assessment

• Assessing a patient entails quantifying the degree of hearing loss and a patient’s speech recognition abilities.

• The American Academy of Audiology (2006) recommends the following:

  • Comprehensive case history

  • Identifying type and magnitude of hearing loss via pure-tone and speech audiometry as well as immittance

  • Measuring loudness discomfort levels (LDLs)

  • Otoscopic inspection and cerumen management

  • Determine need for treatment/referral to physician or need for further tests(e.g., vestibular tests)

  • Counsel patient, family, caregiver on the results and recommendations

  • Assess candidacy and motivation toward amplification

  • Determine medical clearance according to criteria of the Food and Drug Administration

• Assessment should center on communication concerns.

• Structured inquiry helps identify listening circumstances in which a patient is suffering.

• The client Oriented Scale of Improvement (COSI; Dillon, James, & Ginis, 1997) demonstrates a structured-inquiry instrument.

  • It allows patients to nominate up to five situations in which they would like to communicate better.

  • Patients review their descriptions and indicate how much better or worse the situation is now relative to before aural rehabilitation began.

Informational Counseling

• Counseling is ongoing but often has a dedicated block of time for informational counseling to be used, usually after the assessment and then again, before and after a listening device is fitted.

• The initial session summarizes assessment results and outlines potential steps.

• Figure 10-13 presents a schematic representation that describes how an informational counseling session might progress.

• Table 10-4 Do's and don'ts for describing an Audiogram to a patient

• Audiologists provide a written outline of what the patient can expect through the aural rehabilitation plan.

Development of a Plan

• Three elements of evidence-based practice (EBP):

  • Research evidence

  • Clinician’s experience

  • The patient’s goals and preferences

• Implementing EBP involves:

  • Joint goal setting

  • Shared decision making

• In joint goal setting, a clinician and patient forge a partnership that identifies meaningful goals and desired outcomes.

• Defining a goal is the first step in identifying strategies to solve a hearing-related difficulty and may be assessed in an intervention.

• Caveat for Goal Setting: Sometimes a clinician must listen for the hidden message when patients talk about their goals, and may have to help the patient clarify true goals.

• Shared decision making means that neither the clinician nor the patient alone decides how the patient’s goals are to be addressed.

• Once they have an appreciation of the nature and extent of the problem, they make joint decisions about which course to pursue.

Implementation

• Entails provision of:

  • Hearing aid

  • Cochlear implant

  • Assistive listening devices (ALD's)

  • Tinnitus management.

Hearing Aids

• Determine whether a patient is a candidate.

• Audiological criteria and motivation.

• Perform a hearing aid evaluation; provide hearing aid fitting and orientation.

• Establishing an appropriate use pattern is a prominent goal.

• Figure 10-14 example

Candidacy and Motivation

• Motivation to use is important but often overlooked.

• Factors that influence:

  • Subjective factors

  • Input from family members

  • Professional input

  • Patients’ attitudes and values.

• Survey (National Council on Aging, (1999); Barriers to wearing hearing aids:

  • Half cited the expense.

  • $20\%$ expressed concern about vanity.

  • The most common responses were My hearing is not bad enough and I can get along without one

  • According to some respondents, [hearing aids] will not help with my specific problem

• Figure 10-15, Patients pass through stages:

  • Contemplation

  • Preparation

  • Action

  • Maintenance

• Figure 10-15

  • The stages of motivation.

Establishing a Use Pattern

• Figure 10-16 Three identifiable hearing aid use patterns:

  • Full-time users.

  • Patients who rejected them.

  • Some individuals decide they only need it for specific settings at some point, but not necessarily full time.

• Figure 10-16, patients passes through stages.

• Reasons to not wear devices (McCormack & Fortnum, 2013):

  • Uncomfortable to wear

  • Difficult to handle

  • Overwhelmed by background noise

  • Had unrealistic expectations.

  • “Tinny” or loud speech sounds

  • The patient may have wanted one kind of hearing aid, but the audiologist prescribed another, one that may have been more appropriate for the hearing loss configuration, but ultimately, a wrong choice because the patient now rejects it.

Follow-Up

• Follow-up appointments consist of these factors:

  • Returning about three or more times during the first year.

  • Adjustments in the programming of the hearing aid (e.g., adjustment in the device to increase the gain).

  • Routine service (e.g., clearing of a clogged tube), and counseling (e.g., training to use the telephone).

• Figure 10-17 example handout for new hearing aid users.

• Auditory training to accelerate adjustment and improve residual hearing use.

• There should be sufficient time between the hearing aid fitting and the onset of auditory training

Outcomes Assessment

• Common outcome measures include direct measurement of performance, interviews, observation of performance, self-report scales and questionnaires, and daily logs.

• Determine whether activity limitations and participation restrictions have resolved.

• The Gothenburg Profile (Ringdahl, Eriksson-Mangold, & Andersson, 1998) can also be used as an outcomes assessment instrument.

• Benefit: Improvement gained in aided vs. unaided listening.

• Satisfaction: Patient’s contentment; correlated with the benefit but influenced by expectations.

• The International Outcome Inventory for Hearing Aids (IOI-HA) includes seven items, which together query the patient about performance, benefit, usage, and satisfaction.

Follow-Up

• Aural rehabilitation is a process; the plan should be adaptable.

• Predicaments change; plans may require fine-tuning.

• Figure 10-19 illustration of a patient's situation. Before it was to conserve in a quiet setting. Following successful aural rehabilitation she wants a new one by being able to communicate on the telephone, but is now not. The plan must adapt to changing needs

• Check-ins: Routine written materials, short letters, email, Internet chat rooms.

• Annual visits, hearing tests, and hearing aid checks.

Tinnitus Intervention

• Assessment and intervention.

• Few patients pursue treatment (Kochkin et al., 2011).

• Tinnitus intake interview questions:

  • What does your most bothersome tinnitus sound like?

  • Is your tinnitus louder on one side of your head than the other?

  • Would you please describe the onset of your tinnitus?

  • How long have you had your tinnitus?

• The patient might complete a questionnaire.

  • Given tinnitus cannot be measured objectively, it helps to quantify its degree or disability.

  • Quantifiable question themes consist of: "location", "pitch", "constancy", "composition", "fluctuation", "loudness", "conditions that make the tinnitus worse", "annoyance", "effects on concentration and sleep", and "depression."

• Medical and audiological measures include:

  • Comprehensive audiological and Site-of-lesion testing.

  • Otoscopic examination.

  • Impedance audiometry.

  • Vvestibular and balance tests.

  • Head magnetic resonance imaging (MRI).

  • Vascular studies such as angiography.

• The audiologist might administer a tinnitus assessment battery, typically consisting of pitch and loudness matching tasks, perceptual location, minimum masking level, and post masking effects.

• No known cure exists; options provide relief or control.

• Table 10-5: Apps that provide sounds/soundscapes for masking.

• Table 10-6: Common treatments summarized: Masking, relaxation therapy/meditation, biofeedback, counseling, and pharmacological interventions.

• Some tinnitus sufferers enroll in a self-help group; The American Tinnitus Association (ATA).

CASE STUDY

• One Size Doesn’t Fit AllAural rehabilitation is not “one size fits all.”

• Doug Kammer: he doesn't know at some level that he has a hearing loss and that if he wants to be an effective member of a work team, he must communicate. comprehensive plan are far ideas.

• Mary Saunders: Life seems to be moving by her so fast that she is overstressed with three children and sole breadwinner.

• Carl King: Since the passing of his wife, his children are concerned about his psychological well-being. With no one to talk to, it just doesn't seem necessary.

FINAL REMARKS

• Aural rehabilitation begins with a solid understanding of the patient.

• Adults vary in culture, demographics/reactions to hearing loss, communication needs/problems, and phases of adjustment.

KEY CHAPTER POINTS

• Most adults lose their hearing gradually over time; loss is greatest in high frequencies.

• Life-factor influences pertain to self, home, work, recreation, and community.

• Cultural, ethnic, and racial backgrounds affect the response to hearing loss,

• Adults with hearing loss may have more psychosocial and vocational difficulties.

• Determine how hearing loss affects daily life and spending time in different settings plus communication partners.

• Tinnitus and vertigo accompany hearing loss in adults.

• Patient journey: Pre-awareness, awareness, movement, diagnosis, rehabilitation, and resolution.

• Aural rehabilitation plan: Assessment, counseling, development/implementation, outcomes/follow-up. Plans shall be customized.

• Develop a partnership, problem-solving strategy, goal setting/shared decision making.

• Motivating hearing aid use entails education, value examination, and establishing use pattern.

• Adults receiving hearing aids do not use them due to factors.

• Those that suffer from tinnitus may undergo testing

• Aural rehabilitation is a process, so the plan changes over time.

TERMS AND CONCEPTS TO REMEMBER

• Prevalence

• Life factors and life stages

• Culture

• Cultural and linguistic competency

• Stigmatization

• Tinnitus

• Vertigo

• Deaf culture

• Americans with Disabilities Act (ADA)

• Patient-centered orientation

• Patient journey

• Formulating objectives

• Joint goal setting

• Shared decision making

• Use patterns

• Orientation session

• Outcome measure

• Performance, Benefi
  t, Usag
  e, Satisfactio
  n Hearing aid us
  e patter
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  Third-party disability

KEY RESOURCES

• The NAL Client Oriented Scale of Improvement (COSI)

• Tool for Assessing How a Patient Spends a Typical Day

• The International Outcome Inventory for Hearing Aids (IOI-HA)

Appendix

• Topics covered in a three-class group follow-up program for new hearing aid users