analysis of prefitting versus postfitting hearing aid ... · ing handicap. since the introduction...

*Louisiana Tech University, Ruston; †University of Florida, Gainesville

Reprint requests: Brett E. Kemker, Ph.D., FAAA, Department of Speech and Hearing, Louisana Tech University, Ruston, P.O. Box3165, Ruston, LA 71272; Phone: 318-257-4764; E-mail: [email protected]

Analysis of Prefitting versus PostfittingHearing Aid Orientation Using the GlasgowHearing Aid Benefit Profile (GHABP)

Brett E. Kemker*Alice E. Holmes†

Abstract

Results of this study demonstrate the advantages of both pre- and postfittinghearing aid orientation (HAO) sessions. This study demonstrated that HAOcounseling is helpful in expediting hearing aid benefit and satisfaction throughthe education of our clients and that this benefit and satisfaction is age depend-ent as measured by the Glasgow Hearing Aid Benefit Profile (GHABP)(Gatehouse, 1997). Patients with greater initial disability, as identified by item1 of the GHABP, receive significant benefit from prefitting and/or postfittingcounseling as compared to patients receiving no counseling. Implications ofthese findings are discussed.

Key Words:Age, benefit, disability, Glasgow Hearing Aid Benefit Profile, hear-ing aid orientation, hearing aids, perceived handicap, prefitting hearing aidorientation, satisfaction

Abbreviations: AR = Audiologic rehabilitation; GHABP = Glasgow HearingAid Benefit Profile; HAO = hearing aid orientation

J Am Acad Audiol 15:311–323 (2004)

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Sumario

Los resultados de este estudio demuestran las ventajas de las sesiones deorientación (HAO) previas y posteriores a la adaptación de auxiliares audi-tivos. Este estudio demostró que las HAO son útiles para acelerar el beneficioy la satisfacción con el auxiliar auditivo por medio de la educación de nues-tros clientes, y que este beneficio y satisfacción son dependientes de la edad,conforme lo demuestra el Perfil de Glasgow de Beneficio del Auxiliar Auditivo(GHABP) (Gatehouse, 1997). Los pacientes con mayor discapacidad inicial,identificados por el ítem 1 del GHABP, reciben un beneficio significativo deuna consejería previa y posterior a la adaptación, comparados con pacientesque no reciben tal consejería. Se discuten las implicaciones de estos hal-lazgos.

Palabras Clave: Edad, beneficio, discapacidad, Perfil de Glasgow de Beneficiodel Auxiliar Auditivo, orientación sobre auxiliares auditivos, discapacidad percibida,orientación previa a la adaptación de auxiliares auditivos, satisfacción

Abreviaturas: AR = Rehabilitación audiológica; GHABP = Perfil de Glasgowde Beneficio del Auxiliar Auditivo; HAO = Orientación sobre auxiliares auditivos

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Many factors may influence the suc-cess of new hearing aid users. Onemajor problem is individuals pre-

senting with inappropriate expectations ofhearing aid performance at the initial fit-ting (Kricos et al, 1991). Kricos et al (1991)recommend the candidate receive frank coun-seling regarding realistic expectations forhearing aid benefits, actual use, and dailycare of the hearing instrument. Previousresearch has not addressed the effectivenessof a prefitting hearing aid orientation (HAO).

In other health-care fields, the effec-tiveness of presurgical education, training,and counseling has been reported in severalpapers (e.g., Mumford et al, 1982; Hathaway,1986; Webber, 1990). Specifically, Hathawayfound that patients who receive taped, writ-ten, or verbal preparation generally requiredless pain medication postsurgery and recov-ered faster than patients who did not receivepreoperative preparation. Mumford et alfound that prepared patients are often foundto have a shorter length of hospital stay. Fur-ther, preprocedural education can reduceanxiety, increase coping ability, and shortenthe hospital stays of surgical patients (But-ler et al, 1996). Butler et al evaluated pre-hospital education for total hip replacement(THR) surgery candidates and found theexperimental group to have less anxiety andrequire less occupational therapy and phys-iotherapy than those who received no pre-education. The method of preprocedural edu-cation was the administration of a simpleinformation booklet mailer. The applicationof these findings to the field of audiology,specifically hearing aid provision, is a logicalstep. A prefitting hearing aid orientation(HAO) may be the appropriate vehicle topresent this information.

Ward and Gowers (1980) and Ward (1981)determined the efficacy of postfitting HAcounseling, using either individual face-to-face instruction and/or self-instruction usinga written notebook. The instruction in bothformats significantly improved the scores ofelderly HA users on a test of knowledge ofhearing tactics, compared to a control groupwho received only cursory instruction at thetime of the HA fitting. Superiority of one for-mat over the other was not demonstrated.Using the Hearing Handicap Inventory forthe elderly (HHIE; Ventry and Weinstein,1983), Abrams et al (1992) demonstrated asignificant reduction in degree of perceived

handicap in a group of patients who hadreceived hearing aids and a three-week coun-seling-based program of audiologic rehabili-tation (AR) in a group format. A second sub-ject group who received hearing aids withno training also had a significant reductionin perceived handicap although not as greatas that of the group receiving training. Acontrol group, who did not receive hearingaids nor AR, exhibited no change in degreeof perceived handicap.

Self-perception or “measurement” of one’scurrent condition with regard to disabilityfrom hearing loss has been established as aclinically relevant and accurate method ofidentifying areas in need of remediation(McCarthy et al, 1990). The Hearing Hand-icap Scale (HHS) developed by High et al in1964 was an early attempt to measure hear-ing handicap. Since the introduction of theHHS (High et al, 1964), many self-reportscales for audiologic rehabilitation have beendesigned (Noble and Atherly, 1970; Speaks etal, 1970; Alpiner et al, 1974; Giolas et al,1979; McCarthy and Alpiner, 1980; Newmanand Weinstein, 1986; Demorest and Erdman,1987; Kaplan et al, 1991). These scales weredesigned to assess perceived levels of dis-ability, patient and significant-other atti-tudes and coping abilities toward hearingloss, communication performance in differentenvironments, and hearing aid performanceand use (Hutton, 1991; Schow et al, 1993).Although the HHIE, HHIA, and the SAC arerecommended by the American Speech andHearing Association (ASHA, 1997), handi-cap scales have not been totally accepted inthe field of audiology as valid measures ofhearing aid user outcomes (Schow et al, 1993).

The Glasgow Hearing Aid Benefit Profile(GHABP; Appendix) is a hearing handicapscale that is designed to be a measure ofindividual client concern and expectationaccountability (Gatehouse, 1997). With thisquestionnaire, the patient identifies up toeight listening situations considered by thepatient to be difficult. For each situation,the patient rates the amount of difficulty,the level of annoyance, the proportion of timethe patient’s hearing aid is worn during thesituation, the amount of help provided bythe hearing aid, the level of difficulty in thesituation with the hearing aid, and the degreeof satisfaction with the hearing aid. TheGHABP represents a client-focused rehabil-itation protocol. The importance of this is

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that it sets up a paradigm in which the clientsidentify their own communication difficul-ties and then utilize the audiologist as aresource for solving these communicationproblems. This concept of patient empower-ment has its theoretical basis in the work ofeducators and psychologists who have workedprimarily with socially disadvantaged popu-lations (Wallerstein and Bernstein, 1988).The empowerment philosophy is based onthe idea that to be healthy, people must beable to bring about changes, not only per-sonally but also socially (Feste and Anderson,1995). Rappaport (1987) defines empower-ment as a “process by which people gain mas-tery over their lives.” A well-designed HAOshould be the vehicle for empowering ourpatients.

It is widely accepted within our profes-sion that self-perceived measures of disabil-ity, handicap, hearing aid use, and hearingaid satisfaction are all components of a pos-itive amplification intervention outcome. TheGHABP is a simple and effective tool to eval-uate these important parameters. Using theGHABP, this investigation evaluated prefit-ting versus postfitting HAO, in order to deter-mine the most effective timing to attain thepositive patient outcome measures neces-sary for improved communication usingamplification.

METHOD

Participants

Forty-five individuals participated inthis investigation. All individuals weresolicited from the clinic population of theDepartment of Audiology and Speech Pathol-ogy at the Gainesville Veterans Administra-tion Medical Center (GVAMC). Subject agesranged between 60 and 80 years with a meanage of 70.70 years (see Table 1). Subject selec-tion was based on a hearing loss criterion ofa bilateral sensorineural hearing impair-ment with pure-tone thresholds poorer than40 dB HL at 1000 or 2000 Hz in the betterear (Ventry and Weinstein, 1983). Pure-toneaverages (i.e., 500Hz, 1000 Hz, 2000 Hz) forparticipants were 70 dB HL or better. Sub-ject word-recognition scores at 40 dB SL wereabove 61% for each ear. All participants werenative English speakers with adult onsethearing loss. All participants were new hear-ing aid users, fitted with conventional ana-log hearing aids upon inclusion in the study.Those patients being followed by the VisualImpairment Service Team (VIST) programwithin the VA system were excluded fromthe study. Potential participants werescreened using the Mini-Mental Status Exam-

Prefitting Hearing Aid Orientation/Kemker and Holmes

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Table 1. Group Age and Audiometric Results

Prefitting Postfitting Control

Age m = 69.53 m = 70.28 m = 72.06

SD = 6.09 SD = 5.63 SD = 5.66

PTA (r.) m = 36.13 m = 38.73 m = 40.07

SD = 9.82 SD = 8.74 SD = 10.88

PTA (l.) m = 36.93 m = 37.40 m = 38.06

SD = 8.51 SD = 7.95 SD = 8.26

HFPTA (r.) m = 51.53 m = 54.27 m = 53.07

SD = 8.86 SD = 8.98 SD = 8.99

HFPTA (l.) m = 53.13 m = 52.93 m = 51.87

SD = 6.8 SD = 9.68 SD = 6.98

SRT m = 29.33 m = 30.53 m = 32.93

SD = 9.37 SD = 5.50 SD = 7.70

PBMAX m = 78.80 m = 85.71 m = 82.56

SD = 9.31 SD = 8.41 SD = 8.95


ination (Folstein et al, 1975) to rule out cog-nitive pathology as a possible confoundingvariable. A score of 23 or higher was requiredfor inclusion in the study. Subject confiden-tiality was maintained by assigning a num-ber to all participants.

Instrumentation

All participants received a complete audi-ologic evaluation that included otoscopicinspection, standard pure-tone air- and bone-conduction testing, speech reception thresh-olds, and word-recognition testing. Testingwas completed by a certified audiologist usinga diagnostic audiometer (Grason Stadlermodel 1710) under headphones (model TDH50P) in a double-walled test chamber (Tra-coustics model RS 254 BS) meeting AmericanNational Standards Institute [ANSI] codeS3.1-1991. Speech testing including speechreception thresholds and word recognition(CID22) was completed using a compact discplayer (TEAC model PD 80 mkII) routedthrough the audiometer.

For all hearing aid fittings, the NationalAcoustic Laboratories Revised version (NAL-R) target gain measures was used. This for-mula for target gain is the standard procedurefor hearing aid fittings at the GVAMC.

All equipment was calibrated to meetthe standards of the ANSI (1989, 1991). Lis-tening checks were performed daily. Audio-metric results for the three groups were con-sistent (see Table 1).

Protocol

Three groups of 15 participants eachwere selected using a systematic randomsampling scheme. Word-recognition scoresof participants were monitored for each groupto insure balancing. At the time of the cast-ing of earmold impressions at the GVAMCaudiology clinic, all veterans agreeing to takepart in the study completed the Mini-MentalStatus Examination (Folstein et al, 1975)and items 1 and 2 of the GHABP (Gatehouse,1997). These items were randomized to elim-inate any fatigue factors or order effects.

The control group received no HAO. Theother two groups received the same HAOseries consisting of two one-hour sessions.One of these groups received the last of theHAO sessions at least one week preissue,while the other of these groups will receive

the last of the HAO sessions at least oneweek post-issue. The two HAO sessions wereadministered approximately one week apart.The control group was offered the opportunityto attend an HAO after this study had beencompleted. The HAO sessions were admin-istered to all groups by the same two audi-ology graduate students, who were not awareof the specific goals of the investigation. TheGVAMC secretary throughout the course ofthe study recorded the number of patientcontacts per subject. The administration of thefinal assessment took place five weeks fromthe time of initial hearing aid fitting. Assess-ment included the remainder of the GHABP.

HAO Content

The design of the hearing aid adjust-ment program used in this study was a mod-ification of one developed by Holmes at theUniversity of Florida. It is a combination ofcommunication skills training and HAO.Nonverbal and situational cues are addressedas well as information on environmentalmodifications to facilitate best possible lis-tening situations. Expressive skills, whichenable individuals with hearing impairmentto communicate their needs to others in anassertive, nonthreatening manner is alsopart of this protocol. The participants receivedinformation and were counseled on their spe-cific hearing impairment and needs. Thisincluded basic anatomy and physiology, theaudiogram, and how these topics apply totheir personal hearing concerns. Care andproper maintenance of the hearing instru-ment were covered in detail. A one-on-onecounseling session took place in which eachpatient received a written packet of materi-als that went along with the sessions.

Statistical Method

The study design consisted of a ran-domized, double-blinded, 3-arm trial. Patientsin the study were randomized to one of threetreatment groups with balanced group allo-cation (n = 15 per group). One patient ulti-mately was excluded from the study due tothe occurrence of unusual circumstances dur-ing his participation in the study (certainextraneous events escalated this individualto social celebrity status after prefitting meas-ures were obtained and before postfittingmeasures were completed). Baseline char-


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acteristics of interest and baseline levels ofcertain outcome measures were determinedfor each subject prior to the start of the study.Outcome variables of interest were assessedonly after patients completed their respectivestudy group protocols. Simple summary sta-tistics and pairwise Pearson and Spearmancorrelations among response variables andbaseline covariates were initially consideredalong with clinical relevance and importancein arriving at a final subset of covariates andoutcome measures to be used in the analysis(Snedecor and Cochran, 1980, pp. 175–193[correlations], 274–297 [transformations]).Outcome variables that were analyzed rig-orously included items 3, 4, 5, and 6 from theGlasgow Hearing Aid Benefit Profile(GHABP) scoring instrument. GHABP item1 (the prefitting analogue of item 5) and item2 were considered as potential confoundersor moderators of treatment effect.

Differences in outcome measuresbetween experimental groups were evalu-ated in the context of several different sta-tistical models. Analysis of covariance(ANCOVA) was used to compare group meansadjusted separately for each baseline covari-ate of interest (parallel slopes model) andalso to determine if differences among groupmeans depended on the level of the baselinecovariate being considered (nonparallel slopesmodel) (Fleiss, 1986). Given the study designand sample size, covariates were only con-sidered individually with regard to theirinfluence as confounders or moderators oftreatment effect so as to avoid possible “over-fitting” of the data. Analysis of variance(ANOVA) was used to compare unadjustedresponse means among the experimentalgroups. For each response variable, prelim-inary model fitting was carried out so thatresiduals from the model fit could be assessedfor distributional normality and the pres-ence of any systematic pattern of variation,which could be removed by transformation.This residual analysis indicated that the dis-tributional properties of item 3 from theGHABP appeared to benefit from arcsinesquare-root transformation. The within-subject Pearson correlation between pre- andpoststudy determinations of several of theoutcome variables was also evaluated in orderto decide if the poststudy determination or thedifference between pre- and poststudy deter-minations would be the more appropriateform to analyze. (A correlation coefficient

greater than 0.5 favored the difference score,while a correlation coefficient less than 0.5favored the poststudy score.) These correla-tions were such that the difference betweenitems 1 and 5 from the GHABP (pre- versuspoststudy r = .54). The significance of inter-actions between group and covariate effectsin the nonparallel slopes ANCOVA modeland group main effects in the parallel slopesANCOVA and ANOVA models were allassessed by F test (Fleiss, 1986). Tukey’spairwise multiple comparison procedure wasused to evaluate pairwise differences amonggroup means while maintaining an experi-ment-wise significance level of 0.05 (Fleiss,1986). When a significant interaction betweencovariate and group effects was detected, thecovariate cutpoint was determined above orbelow which a pairwise difference betweengroup means first became significant at aTukey-adjusted significance level of 0.05.Final model fits were all evaluated for highlyinfluential observations or outliers usingCook’s distance, a measure of the relativechange in model regression coefficients thatwould occur if a particular observation wereremoved (Weisberg, 1980). Observationsdemonstrating a Cook’s distance >1 wereconsidered to be highly influential and thussuspicious. Patient data values wererechecked for validity in this situation, andmodels were refit with the influential obser-vation excluded in order to characterize thenature of the influence. R-squared was alsocalculated for each model fit to determinethe percent of variability in the outcomemeasure accounted for by each model.

RESULTS

Glasgow Hearing Aid Benefit ProfileDifference of Items 5 and 1 (GHABP5-1) (Difference Score)

Items 1 and 5 on the GHABP aredesigned to reflect initial and residual dis-ability of the patient respectively. Eachpatient was asked to address the first itemon the GHABP. This item pertained to thepatient’s unaided listening difficulty in spe-cific situations and was administered at thetime the ear molds were cast. Approximatelyone month postfitting, the patient was askedto answer item 5, which is actually a re-askingof item 1 after the introduction of hearing


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aids. No significant differences were observedamong unadjusted GHABP5-1 differencescore group means (Table 2).

Glasgow Hearing Aid Benefit ProfileItem 3 (GHABP3)

The third item on the Glasgow HearingAid Benefit Profile (GHABP3) refers to theamount of time the patients spend wearingtheir hearing aids (Table 3). No significant dif-ferences were observed among unadjustedGHABP3 group means nor among groupmeans adjusted separately for each covariateof interest in parallel slopes ANCOVA mod-els. Similarly, no significant covariate-depend-ent differences were observed among groupmeans in nonparallel slopes ANCOVA mod-els that included the same covariates. Thepreviously described pattern did not changewhen controlled for initial disability

(GHABP1) and perceived hearing handicap(GHABP2).


The fourth item on the GHABP proposesa means to assess hearing aid benefit (Table4). No significant differences were observedamong unadjusted GHABP4 hearing aid ben-efit group means nor among group meansadjusted separately for each covariate ofinterest in parallel slopes ANCOVA models.Similarly, no significant covariate-dependentdifferences were observed among groupmeans in nonparallel slopes ANCOVA modelsthat included the same covariates. The pre-viously described pattern did not changewhen controlled for initial disability(GHABP1) and perceived hearing handicap(GHABP2).


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Table 2. The Summary Statistics for the Difference Score for GHABP Items 5 Minus 1 (GHABP5-1)

Group N Mean SD Median Minimum Maximum

Control 15 -37.91 11.48 -37.50 -60.00 -18.75

Prefit 15 -45.25 12.13 -43.75 -75.00 -25.00

Postfit 14 -35.05 21.33 -33.12 -66.66 0.00

Table 3. Simple Summary Statistics Showing Patient Hearing Aid Use (GHABP3)

Variable Group N Mean SD Median Minimum Maximum

Control 15 85.50 14.64 87.50 56.25 100.00

Prefit 15 88.69 12.75 93.75 62.50 100.00

Postfit 14 83.51 26.34 95.83 25.00 100.00

Table 4. Simple Summary Statistics Showing Patient Hearing Aid Benefit (GHABP4)

Variable Group N Mean SD Median Minimum Maximum

Control 15 57.55 9.84 60.00 31.25 68.75

Prefit 15 63.38 14.57 65.00 29.16 83.33

Postfit 14 62.44 18.72 65.62 25.00 100.00

Table 5. Simple Summary Statistics Showing Patient Hearing Aid Satisfaction (GHABP Item 6)

Group N Mean SD Median Minimum Maximum

Control 15 62.44 13.11 65.00 25.00 75.00

Prefit 15 67.58 10.16 66.66 50.00 93.75

Postfit 14 65.68 12.48 68.33 37.50 81.25



The sixth item on the GHABP providesa measure of patient hearing aid satisfac-tion (Table 5). No significant differences wereobserved among unadjusted GHABP6 groupmeasures of hearing aid satisfaction noramong group measures of hearing aid satis-faction adjusted separately for each covari-ate of interest in parallel slopes ANCOVAmodels. Age-dependent and GHABP1-depend-entdifferences among group measures of hear-ing aid satisfaction were observed in non-parallel slopes ANCOVA models (p = 0.026and 0.031 respectively for age x group andGHABP1 x group interaction effects). Inpatients younger than 66 years of age, meanhearing aid satisfaction was significantlyhigher in the postfitting group when com-pared to the control. The postfitting group’smean hearing aid satisfaction was also sig-nificantly greater than the control group’shearing aid satisfaction in patients whoseGHABP1 (initial disability) score was ≥70%.Mean hearing aid satisfaction was signifi-cantly greater in the prefitting group whencompared to the control patients whose ini-tial disability (GHABP1) score was ≥64%.The previously described pattern did notchange when controlled for initial disability(GHABP1) and perceived hearing handicap(GHABP2).

DISCUSSION

The sixth item on the GHABP offers ameans to assess patient hearing aid sat-

isfaction. Patients younger than 66 years ofage in the postfitting group were significantlymore satisfied with their hearing aids thanthose matched subjects in the control group.It would appear that the timing and type ofHAO provided are well received by this agegroup. Different counseling methodologiesshould be investigated regarding those indi-viduals above the age of 66 years.

The postfitting group mean was also sig-nificantly greater than the control groupmean in those patients whose GHABP1 scorewas ≥70%. Patient hearing aid satisfactionwas significantly greater in the prefittinggroup compared to the control group in thosepatients whose GHABP1 (initial disability)score was ≥64%. This suggests that patientswith greater initial disability, as identified by

the GHABP, receive significant satisfactionfrom prefitting and/or postfitting counselingas compared to patients receiving no coun-seling. This finding would agree with Brooks(1979). Further investigations targeting ele-vated initial disability scores as part of theinclusion criteria would reduce ceiling effects.

Patients receiving prefitting counselingshowed slightly greater, but not statisticallysignificant, improvements regarding situa-tional listening difficulties when compared tothe postfitting and control groups. Theseresults suggest that client familiarity andcompetency with the hearing instrumentmay be obtained more efficiently with pre-fitting counseling than with the traditionalno-counseling and postfitting-counselingregimes. This may not suggest that prefittingcounseling is actually better but, rather,client exposure to hearing instrument careand use strategies should be expedited, oncehearing aid intervention is pursued.

The third item on the GHABP (GHABP3)refers to the amount of time the patient spentwearing their hearing aids. No significantdifferences were observed among the con-trol, prefitting, and postfitting groups usingthese measures. The homogeneity of thiscohort may have considerable influence on theamount of time the patient wears his or herhearing aids. Outstanding patient compli-ance and cooperation from this age group ofveterans should be noted. All of the partici-pants do receive their health care and hear-ing aids free. This may be an uncontrollablecondition possibly responsible for creatingelevated subject response. In addition, five-weeks-postfitting measures may possibly stillbe within the “honeymoon” period. A longi-tudinal study measuring the amount of timethe patient wears their hearing aids, in thisand other “fee-for-service” populations, iswarranted.

The fourth item on the GHABP offers ameans to assess hearing aid benefit. No sig-nificant differences were observed amongthe three experimental groups. It cannot beruled out that free acquisition of hearingaids rendered the measurement tools used inthis study insensitive to these elevated dif-ferences in hearing aid benefit betweengroups.

The GHABP is a clinical tool capable ofevaluating various aspects of clinical proce-dure while maintaining clinical suitabilityand utility. While maintaining a client-driven


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agenda, it is designed to provide numericaloutcome measures for quality assurance andin developing individual patient audiologicmanagement strategies.

CONCLUSIONS

Patients younger than 66 years of age inthe postfitting HAO group were signifi-

cantly more satisfied with their hearing aidsthan those in the control group. Patientswith greater initial disability, as identified bythe GHABP item 1, receive significant ben-efit from prefitting and/or postfitting coun-seling compared to patients receiving nocounseling. The results of this finding indi-cate the importance of audiologic HAO for per-sons with more initial disability as meas-ured by item 1 on the GHABP. Furthermore,it indicates that the effectiveness and appro-priateness of an HAO may be better suitedfor those under the age of 66 years. This cer-tainly points out the need for further inves-tigation into development of appropriate age-related hearing aid care and use deliverymodels.

Traditional protocol for the elderly clientwith hearing impairment has been one of vol-untary postfitting HAO. The results of thisstudy demonstrate the advantages of bothpre- and postfitting HAO sessions. This studydemonstrated that HAO counseling is help-ful in expediting hearing aid benefit and sat-isfaction through the education of our clientsand that this benefit and satisfaction is agedependent—HAO being more appropriate forour younger patients (>66 yr.) and less appro-priate, by itself, for our elderly patrons. Thisappears to be true if the client presents witha realistic level of perceived hearing disabil-ity, which echoes Kricos et al (1991). Thismay suggest that a combination of pre- andpostfitting counseling may be the best clini-cal procedure to ensure hearing aid acceptancethat confirms Brooks’s (1979) findings. Fur-ther investigation is needed to validate theefficacy of such a model considering variouslevels of initial disability and age.

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APPENDIX

Glasgow Hearing Aid Benefit Profile



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We have dealt with some of the situations which in our experience can lead to difficulty with hear-ing. What we would now like you to do is to nominate up to four new situations in which it is impor-tant for you as an individual to be able to hear as well as possible.



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Source: Gatehouse, 1997.


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