quantifying the obvious: the impact of hearing instruments...

By Sergei Kochkin, PhD, and Carole M. Rogin, MA

At a press conference in May 1999,James Firman, PhD, president andCEO of the National Council on the

Aging (NCOA), released some of the find-ings from what is perhaps thelargest study ever conducted onthe effects of untreated hearing losson adults as well as their families.The study, commissioned by theNCOA, was funded by the HearingIndustries Association (HIA). Theactual field work and analysis wasconducted by the Seniors ResearchGroup utilizing the National FamilyOpinion Panel (NFO).

The report1, which is volumi-nous, was first made available tokey researchers in the industryin draft form in December 1998.Because of its size, it is consid-ered inaccessible to the typicalhearing health care stakeholder.To make the results more wide-ly known, the senior author ofthis paper conducted an “execu-tive” level analysis of the HIA-NCOA database and reportedon the findings at the EuropeanHearing Industries Manufactur-ers Assn. (EHIMA) World Hear-

ing Conference held in Brussels in May1999 and to the Hearing IndustriesAssociation (HIA) in June 1999 in Min-neapolis.2 A summary of this presenta-tion as well as the draft findings of the

NCOA study were published by theindustry journals in July 1999.3,4

The purpose of this article, whichreports on the responses of 2069 hearing-impaired individuals and 1710 of theirfamily members or friends, is to presentthe executive-level findings of the finalstudy with the expectations that hearinghealth care providers and manufacturerswill use this information as a springboardfor repositioning the hearing care indus-try for the new millennium.

Activity LevelRespondents were asked to indicate

the extent (times per month) to whichthey engaged in 13 activities. Six of theactivities were solitary in nature whileseven involved other people. Total solitaryand social activity scores were also calcu-lated. As shown in Table 2, hearing instru-ment users are shown to have the samelevel of solitary activity as non-users. How-ever, hearing instrument users are morelikely to engage in activities involving

Quantifying the Obvious: The Impact of HearingInstruments on Quality of LifeNCOA survey of nearly 4000 people finds significant quality-of-lifedifferences between users and non-users of hearing instruments

A survey of 2069 hearing-impairedindividuals and 1710 of their familymembers reveals that hearing instrumentusers are likely to report improvementsin their physical, emotional, mental andsocial well-being. Users of hearinginstruments on average are moresocially active and avoid extendedperiods of depression, worry, paranoiaand insecurity compared to non-userswith hearing loss. Additionally, familymembers and friends are more likely tonotice these benefits than the actualusers themselves.

�RESEARCH

Sergei Kochkin, PhD, isdirector of market dev.and research for KnowlesElectronics, and ischairman of the HIAMarket Dev. Cmt. CaroleM. Rogin, MA, ispresident of the HIA andhas served theorganization for 20 yrs.

Key to Graphs & TablesThe 2069 hearing-impaired respondents(and, where noted, the responses of 1710of their family/friends) were separated intofive even quintiles by the severity of theirhearing losses (i.e., Quintile 1 representsthe 20% of those with the mildest hearinglosses while Quintile 5 represents the20% of those with the most severe loss-es) as measured by the AAO-HNS’s FiveMinute Hearing Test (FMHT). In the fol-lowing graphs and tables, these five quin-tiles are further separated into twogroups: users and non-users of hearinginstruments. Asterisks (*) next to the quin-tile number in the figures denote levels ofstatistical significance: ** = 95% or higher;* = 85-90% (suggestive of trends only).For a complete description of the surveymethodology and statistical reporting,please see the section, “Study Methods,Survey Parameters & Quintiles, andStatistical Reporting.”

Reprinted with permission from The Hearing Review®, Los Angeles, CA. All rights reserved.

JANUARY 2000 THE HEARING REVIEW

� Sampling: In November 1997, a shortscreening survey was mailed to 80,000members of the National Family Opinion(NFO) panel. The NFO panel consists ofhouseholds that are balanced to the latestU.S. census with respect to market size,age of household, size of household andincome within each of the nine censusregions, as well as by family versus non-family households, state (with the exceptionof Hawaii and Alaska) and the nation’s top-25 metropolitan statistical areas.

The screening survey covered only threeissues: 1) physician screening for hearingloss; 2) whether the household had a per-son “with a hearing difficulty in one or bothears without the use of a hearing aid”, and3) whether the household included a personwho was the owner of a hearing instrument.This short survey helped identify nearly15,000 hearing-impaired individuals andalso provided detailed demographics onthose individuals and their households. Theresponse rate to the screening survey was65%. In Dec. ‘97, an extensive survey wassent to 3300 hearing instrument owners withtabulation of the data occurring in Feb. ‘98.

The response rate for the hearing instru-ment owner survey was 83%. The achieveddatabase served as input into Knowles Elec-tronics MarkeTrak V studies.5-7 The data pre-sented in the MarkeTrak panel refer only tohouseholds as defined by the U.S. Bureauof Census (i.e., people living in a single-fam-ily home, duplex, apartment, condominium,mobile home, etc.). People living in institu-tions have not been surveyed; these wouldinclude residents of nursing homes, retire-ment homes, mental hospitals, prisons, col-lege dormitories and the military. Given thata nationally representative sample of morethan 15,000 hearing-impaired individualshad been identified by Knowles Electronics,it was decided to resurvey a sample of theMarkeTrak V panel and their spouse (orclose friend). A sample of 3000 individualswith a self-admitted hearing loss ages 50and over were randomly drawn from theMarkeTrak panel. Equal samples of 1500hearing instrument owners and non-ownerswere drawn from the panel.

� Survey Design and Response. Utilizinginformation from previously developed indus-try surveys8,9, interviews with industryresearchers and academia, and a review ofthe literature on the psychosocial and physicalaspects of hearing loss10-23, Senior ResearchGroup designed an eight-page questionnairecomprised of 300+ questions for the individualwith hearing loss and a four-page question-naire comprised of 150 questions for thespouse or family member of the identifiedrespondent. The comprehensive survey cov-ered a myriad of topics ranging from self andfamily perceptions of benefit of hearing aids toattitudes towards hearing health and hearinginstruments. In addition, a number of person-ality scales24-27 deemed relevant to this studywere included in the survey.

The National Family Opinion Panel(NFO), which conducted the field work forthis study in the spring and summer of 1998,sent respondents one questionnaire forthemselves and one for their spouse, family

member or close friend to complete. Thehearing-impaired respondent who receivedthe survey packet was asked to give thesurvey to the family member or friend oftheir choice who was most familiar withthem. While hearing instrument owner andnon-owner samples were matched onimportant census demographics, NFO wasunable to match them on severity of hearingloss, since hearing loss was not measuredin the MarkeTrak screening survey. A $1cash incentive was mailed with each survey.

Response rates were high among bothhearing-impaired individuals and their familyor friends, 79% and 71% respectively (sam-ple sizes of 2364 and 2132 respectively).After analyzing the returned surveys for use-ability (e.g., minimal missing information), inexcluding the substantial number of hearingaid owners who rarely or never used theirhearing aids, and in choosing family surveyreturns which also had a concurrent respon-dent survey, the final sample sizes forrespondents and family members werereduced to 2069 and 1710 respectively.

� Hearing Loss Assessment Measureand Use of Quintiles: In addition to quality-of-life items, a paper and pencil assessmentof hearing loss was administered with theanticipation that the results of this assess-ment would be used to control for hearingloss when comparing the quality of life ofhearing instrument users and non-users.The key hearing assessment tool used wasthe American Academy of Otolaryngology-Head and Neck Surgery’s Five Minute Hear-ing Test (FMHT).28 The FMHT is a 15-ques-tion test measuring self-perceived hearingdifficulty in a number of listening situations(e.g., telephone, multiple speakers, televi-sion, noisy situations, reverberant rooms),as well as self-assessments of some signsof hearing loss (e.g., people mumble, inap-propriate responses, strain to hear, avoidsocial situations). Each item of the FMHT istraditionally scored on a four-point scale,using the values “never,” “occasionally,”“half the time” and “almost always.” Thedevelopers of the NCOA survey utilized afive-point Likert attitude scale with end-pointanchors of “strongly agree” and “stronglydisagree.” Koike et. al28 have shown that theFMHT is significantly correlated with stan-dard audiologic measures, such as speechreception thresholds, speech discriminationscores, air conduction thresholds and puretone measures.

A factor analysis (minimum eigenvalue =1) of the 15-item FMHT demonstrated that itis a unidimensional test. Consequently,respondents’ subjective hearing loss scoreswere simply calculated as the mean of the15 items. Respondents were then groupedinto one-of-five hearing loss quintiles basedon their mean overall subjective hearing lossscores. Each quintile represents 20% of thetotal sample. Quintile 1 represents the 20%of respondents with the least severe hearingloss (per the FMHT) and Quintile 5 the 20%with the most severe loss.

The quintile system was utilized for allanalysis as a means for controlling for differ-ences in hearing loss between hearing instru-ment user and non-user samples. The use of

these quintiles allowed us to achieve morevalid comparisons between the two samples.If we were to simply compare responses ofall hearing instrument users with those of allnon-users, without regard to degree of hear-ing loss, the findings would have been mis-leading and, in fact, erroneous. For example,it is widely known that incidence and degreeof depression have been found to increasewith severity of hearing loss. Thus, even ifseverely hearing-impaired people experiencereduced depression after obtaining hearinginstruments, they might still report moredepression than non-users overall, sincehearing instrument users tend to have moresevere hearing loss than non-users. Howev-er, when hearing instrument users arematched with non-users in the same quintile(i.e., a cohort analysis) the differencesbetween them reflect the potential impact ofthe hearing instruments rather than the effectof their degree of hearing loss.

While there is no audiological basis forlabeling hearing loss associated with eachquintile group, it is worthwhile to look at therespondents’ self-perceived hearing losscompared to their resulting quintile classifi-cation based on the FMHT score. Themodal self-perceived hearing loss is as fol-lows: Quintile 1 (mild/moderate), Quintile 2(moderate), Quintile 3 (moderate/severe),Quintile 4 (severe), Quintile 5 (severe/pro-found).

� Statistical Analysis & Reporting: Asstated earlier, close to 500 data points werecollected from respondent and family mem-ber surveys. It is beyond the scope of thispaper to document all of the findings pre-sented in the NCOA final report. This paperinstead will focus on key benefit results withan emphasis on aided versus unaidedresults within hearing loss cohort (quintile).As an example, the final report providesdetailed results for the six items making upthe “anger & frustration” scale in the survey.With few exceptions, we will present onlythe total results for each scale. The majorityof items in the NCOA survey were scoredon a five-point Likert scale.

In general, mean scores are presentedfor both users and non-users by quintile onthe majority of scales. For some items wewill simply present the percent of respon-dents (e.g., was depressed within the pre-ceding 12 months). All of the subscale find-ings for which there are mean results havebeen normalized (i.e., converted to z-scoreswith a mean of 5 and standard deviation of2). This type of normalization is attractive, inthat one can easily discern trends across awide variety of factors and across groups(user versus non-user and by quintile). Forinstance, a score of 5 on each subscale indi-cates that the sample mean score is at the50% percentile; a score of 3 is at the 16%while a score of 7 is at the 84%.

In discernment of trends, statistically sig-nificant differences in means (t-test) or per-centages (z score for differences in propor-tions) at the 95% and 99% or higher confi-dence level have been documented. Giventhe smaller sample sizes in Quintiles 1 & 2

Study Methods, Survey Parameters & Quintiles and Statistical Reporting

continued on page 4

THE HEARING REVIEW JANUARY 2000

other people. With the exception of Quin-tile 4, hearing instrument users areshown to have significantly higher partici-pation in three to four of the seven activi-ties listed. Four of the five quintile hear-ing instrument user groups indicate they

participate more in organized social activi-ties (Fig. 2), while three of the five hear-ing loss groups report they are more like-ly to attend senior centers if they are hear-ing aid users. The most serious hearingloss group (Quintile 5) reports greater

participation in four ofthe seven activities ifthey are hearing instru-ment users.

InterpersonalRelations

The NCOA surveyasked 12 questions con-cerning the respondent’squality of interpersonalrelationships with theirfamily. The questionsused a four-point scaleranging from “a lot” to“not at all” (e.g., “Howmuch can you relax and

be yourself around them?”) and 12 ques-tions concerning negativity (e.g., argu-ments, tenseness, criticism) in the rela-tionship using a four-point scale rangingfrom “often” to “never.” Interpersonalwarmth and interpersonal negativityscores for family, friends and total aredocumented in Table 3. Due to the scaleused, high scores on the interpersonalwarmth variable are indicative of lessinterpersonal warmth while high scoreson the interpersonal negativity denotemore negativity in relationships.

In Fig. 3, it can be seen that interper-sonal warmth in relationships declines ashearing loss gets worse. Hearing instru-ment users in Quintiles 1-3 (mild to moder-ate) are shown to have greater interperson-al warmth in their relationships than theirnon-user counterparts. Referring to Fig. 4,significant reductions in negativity in fami-ly relationships appears to be associatedwith hearing instrument usage in Quintiles

Fig. 2. Activity Levels: Hearing instrument users) are more likely toparticipate in organized social events than non-users. Higher scoresindicate greater monthly participation in activities.

In Table 1, selected demography is presented by quintile for usersand non-users. Sample sizes for respondent and family membersurvey returns are also provided. The cohort groups with minorexceptions are well matched on gender, employment status andmarital status. With respect to the age of respondents, Quintile 1 andQuintile 2 are shown to be significantly older on average by aboutfive and two years respectively.

As shown in Fig. 1 and Table 2, household income is significant-ly related to both hearing loss and hearing instrument usage. Thestriking trend (income differential) in Quintiles 3-5 indicate that themore serious levels of hearing loss have less household income;this is despite the fact that the higher hearing loss non-user groupstend to be employed more often. Quintile 3 and 5 hearing instrumentuser groups are shown to have significantly more earning powerthan non-users and they are more educated. Thus, hearing instru-ment wearers also report that they have “plenty” of discretionary

income more often than non-users. For example, 22% of Quintile 5hearing instrument users report they have plenty of discretionaryincome compared to 8% for the non-users. The discretionaryincome differential for the more severely hearing-impaired samplesis a likely cause of the lower earning power. Because of higher dis-ability levels, communication is probably impacted, resulting in lowerincome and therefore less earning power. Finding a solution to theirhearing loss is exacerbated for these groups, in that lower earningpower means that the respondent is less likely to be able to afford ahearing instrument to correct his/her hearing loss.

In general, the demographics for users and non-users for Quintiles1, 2 and 4 are well matched. However, the age differences should betaken into account, for instance, when evaluating the impact of hearinginstrument usage on relevant variables such as likelihood of attendinga senior center. For Quintile 3, we find hearing instrument users withgreater discretionary income despite the fact that they are less likely tobe in the work force. Finally, Quintile 5 shows significant differences inincome and marginal differences (90% confidence) on most otherdemographics presented in Table 1. With the exception of age in twoquintiles and income in two quintiles, there do not appear to be sys-temic differences between the users and non-users.

Differences in income and age could, of course, be related toimportant outcome measures such as functional health, anxiety,depression, emotional health and sociability. Similarly, the readerwill notice later in this article that there are differences in reportedphysical health between users and non-users which is supportive ofknown experimental studies.14 In turn differences in physical healthcould impact scores on depression, anxiety and self esteem. It is theauthors’ intent to first present univariate results on outcome mea-sures followed by a total sample multivariate analysis to rule outspurious results due to confounding. �

Demographics and Similarities/Dissimilarities of the Quintiles

Fig. 1. Household income by hearing loss quintile for hearinginstruments users and non-users (same data as Table 1).


1 and 2, the hearing loss groups with themildest hearing disability.

Social EffectsForty-seven items in the survey

assessed the social impact of hearing lossand hearing instrument usage. The socialeffects indices are documented in Table 4(on p. 18) with the more important signif-icant findings graphed in Figs. 5-8. Themajority of the items were scored on afive-point Likert scale taking the values“strongly agree” to “strongly disagree.”The scales on sociability assessed aver-age monthly contact with family andfriends by phone and in person.

In Fig. 5, the stigma of hearing loss isshown to increase as hearing loss increas-es. All five non-user groups report theywould be embarrassed or self-conscious ifthey wore hearing instruments, while allfive user groups reported lower stigmati-zation with hearing instruments. We are

not concluding, of course, that usage ofhearing instruments would lead toreduced stigma; most likely hearinginstrument users have resolved their con-cerns about the stigma associated withhearing instrument usage more so thantheir non-user counterparts. The high stig-ma scores for non-users is thus more anindicator of their personal barriers to hear-ing instrument adoption.

As hearing loss increases, respondentswere more likely to overcompensate forhearing loss by pretending that they haveheard what people say, by avoiding tellingpeople to repeat themselves, by avoidingasking other people to help them with theirhearing problem, by engaging in compen-satory activities such as lip reading or bydefensively talking too much to cover upthe fact that they cannot hear well. Fig. 6shows that all five hearing instrument usergroups report significantly lower overcom-pensation scores. Family members were

for users and Quintiles 4 & 5 for non-users, we have also recorded differencessignificant at the 85% and 90% confi-dence level; however, in the latter casethe differences should be analytically rec-ognized only in the discernment of trends.Certainly, a result is much more importantif there are significant differences acrossfour or five of the groups than if the resultsare marginally significant, for instance, inonly Quintile 1. Also, there are some qual-ity-of-life issues which are highly signifi-cant (99%+) in Quintile 5 only, in that theissue appears to primarily impact peoplewith a severe or profound hearing loss. Inthese cases, we note this single cohortfinding. However, if a single cohortachieves significance only at the 85% or90% level, while documented in the tablesto follow, we will not report the differenceas a finding in this report. �

Fig. 4. Interpersonal Relationships: Negativity in familyrelationships. Higher scores indicate there is less tenseness, arguments,criticisms, etc.

Fig. 3. Interpersonal Relationships: Interpersonal warmth inrelationships. Higher scores denote less perceived interpersonal warmth.

Study Methodologycontinued from page 2


less likely to observe the impactof hearing instruments on thereduction of hearing loss com-pensatory behaviors than wererespondents.

The greater the hearingloss, the greater the likelihoodthat respondents will reportthey are the target of discrimi-nation (Fig. 7). The greater thehearing loss, the greater thelikelihood that respondentswith more serious hearing loss-es were accused of hearingonly what they want to hear,found themselves the subjectof conversation behind theirbacks, were told to “forget it”when frustrated family members were notheard the first time, etc. All hearing lossgroups except Quintile 1 (the mildest hear-ing loss) reported significant reductions indiscriminatory behaviors if they were hear-ing instrument users. While family mem-bers observed greater incidences of dis-criminatory behavior as hearing lossincreased, again they did not see reduc-tions in discriminatory behavior associatedwith hearing aid usage.

Fig. 9 shows a strong relationshipbetween hearing loss and family memberconcerns of safety (“cannot hear warningsigns or instructions from doctor, made aserious mistake, not safe to be alone), aswell as significant differences between

hearing instrument users and non-users.Respondents also agreed that safety con-cerns increase as hearing loss increases.The data, however, indicates that safetyconcerns are significantly higher amonghearing instrument users than non-usersin Quintiles 1-3. Perhaps the realizationthat mistakes were being made or thatunaided hearing loss could result in pos-sible injury was what motivated the cur-rent hearing instrument owner to pur-chase his/her aids. This explanation isconsistent with the findings from Marke-Trak research5, which indicates that thenumber-one motivation to purchase hear-ing instruments is “the realization thattheir hearing loss was getting worse” and

the number-two reason is“family members.”

There were a number ofsocial effects which were cor-related with hearing loss butwere not impacted by hearinginstrument usage. These werenegative effects on the family(e.g., “I find it exhausting tocope with their needs”), familyaccommodations to the indi-vidual with hearing loss (e.g.,“I have to use signs and ges-tures a lot of the time”), rejec-tion of the person with hearingloss (e.g., “Tending to get leftout of social activities becauseof their hearing loss” ) and

withdrawal (e.g., “They tend to withdrawfrom social activities where communica-tion is difficult”). In addition, hearinginstrument usage was not associated withincreased phone or in-person contact withfamily or friends.

Emotional EffectsEighty items in the HIA-NCOA study

dealt with the emotional aspects of hearingloss. Overall results within this categoryfor respondent and family members aredocumented in Table 5. The more impor-tant significant findings are graphically pre-sented in Figs. 10-15.

All five hearing instrument user groupsscored significantly lower in their self-rat-

Fig. 8. Social Effects: Difficulty in communication. Higher scoresare indicative of the effort it takes to communicate for the respondents.

Fig. 5. Social Effects: Stigma. Higher scores indicate the subjectsare embarrassed or self-conscious about wearing hearing instruments.

Fig. 6. Social Effects: Overcompensation of hearing loss. Higherscores indicate the subjects are more likely to hide or cover up theirhearing loss.

Fig. 7. Social Effects: Discrimination. Higher scores are indicativeof subjects who report, for instance, they are “accused of hearing onlywhat they want to hear.”

Fig. 9. Social Effects: Safety concerns from family members. Higher scoresindicate that the respondent’s family is concerned that the person’s hearing losscould impact their safety or the safety of others.


ings of emotional instability. In agreementwith their family members, they were lesslikely to exhibit tenseness, insecurity, insta-bility, nervousness, irritability, discontent-ment, being temperamental and other neg-ative emotions or traits (Fig. 10). Four ofthe five hearing instrument user groupsreported significantly lower tendencies toexhibit anger (e.g., “I sometimes get angry

when I think about my hearing”) and frus-tration (e.g., “I get discouraged because ofmy hearing loss”). As shown in Fig. 11,family members observed significantlylower anger and frustration in all five hear-ing instrument user groups.

In Figure 12a, all five hearing instru-ment user groups reported significantlylower depressive symptoms (e.g., weari-

ness, insomnia, thoughts of death). Four ofthe five hearing instrument user groups(Quintiles 1-4) thus reported significantlylower incidences of depression within thelast 12 months compared to their non-usercounterparts (Fig. 12b). The reduction inthe incidence of depression varied from ahigh of 49% reduction in Quintile 2 to a lowof 18% in Quintile 5; the average reduction


in depression associated with hearing instru-ment usage across all five groups is 36%.

Hearing instrument users in Quintiles2-4 reported significantly lower paranoidfeelings (Fig. 13, e.g., “I am often blamedfor things that are just not my fault”). Notsurprisingly, and in agreement with fami-ly members’ responses, all five non-usergroups (Fig. 14) scored higher on denial(e.g., “I don’t think my hearing loss is asbad as people have told me”). As expect-ed, denial is also inversely related tohearing loss.

Family members and respondentswere asked to indicate if the person withthe hearing loss exhibited anxiety, tense-ness or if they worried for a continuousperiod of four weeks in the previous year.

In addition, the respondents were askedto indicate if they experienced anxietysymptoms (e.g., keyed up or on edge,heart pounding or racing, easily tired,trouble falling asleep). In general, therewere no significant differences in the inci-dence of anxiety as rated by both therespondent and their family members.However, three of the five non-usergroups (1,3,5) exhibited higher anxietysymptoms (Fig. 15). In addition, three ofthe five non-user groups (1,2,5) exhibitedmore social phobias than non-users ofhearing instruments (Fig. 16). Clearly, thereduction in phobia and anxiety associat-ed with hearing instrument usage is morepronounced in individuals with serious-to-profound hearing losses (Quintile 5).

Factors not appreciably impacted byhearing instrument usage in this studywere: sense of independence (e.g., burdenon family, answer for the person with hear-ing loss) and overall satisfaction with life.Although not as conclusive as some of theprevious factors, non-users reported thatthey were more self-critical (e.g., “I dwellon my mistakes more than I should”) andhad lower self-esteem (e.g., “All in all, I aminclined to feel that I am a failure”). Hear-ing loss is highly correlated with self-criti-cism (Fig. 17). There is also some evi-dence, though not as strong, that non-usersare more critical of themselves (Quintiles1,3,5). Finally, as shown in Table 5, therewere no significant differences betweenusers and non-users in traumas experi-

Fig. 10. Emotional Effects: Emotional instability. Higher scoresindicate the respondent described themselves as more fearful, tense,insecure, unstable, nervous, etc.

Fig. 11. Emotional Effects: Anger/Frustration (Family/friend’sassessment). Higher scores indicate family members observed greaterdegrees of anger and frustration in the respondent.

Fig. 12a. Emotional Effects: Depression symptoms. Higher scoresindicate that respondents exhibited more symptoms of depression overthe previous 12 months.

Fig. 12b. Emotional Effects: Percent of respondents depressed inlast 12 months. High scores denote higher incidence of self-reporteddepression.

Fig. 13. Emotional Effects: Paranoia. Higher scores indicate therespondent has more feelings of paranoia.

Fig. 14. Emotional Effects: Denial. Higher scores indicaterespondents were more likely to deny their hearing loss or the impact oftheir hearing loss on their life or the lives of others.


enced in the past year.

Personality AssessmentSeventy-nine items were devoted to

miscellaneous personality scales in addi-tion to the personality measures underemotional effects and social effects. All ofthe personality scales used in this studyare published scales.

In viewing the list of personality traitsmeasured in this study, the reader will rec-ognize that there are literally thousands ofpersonality scales which could have beenused. The scales used here were chosen

by the primary research company, SeniorsResearch Group, based on their researchof the literature and their knowledge ofpersonality correlates associated with theelderly and hearing loss. Many of thescales employed have a considerableresearch background, such as Levinson’sLocus of Control.26 While it would havebeen desirable to administer a comprehen-sive psychological battery to this popula-tion (e.g., California Psychological Invento-ry, Minnesota Multiphasic PersonalityInventory, etc.), it was beyond the scopeand budget of this study to do so. The per-

sonality measures are documented inTable 6 with the key findings in Figs. 18-20.

Family members indicated that therespondent’s cognitive state is affected bytheir hearing loss, particularly if the hear-ing loss is “severe” to “profound.” In Fig.18, Quintiles 4 and 5 indicate that hearinginstrument usage is associated withimprovements in family perceptions of theperson’s mental and intellectual state. Non-users were more likely to be viewed asbeing confused, disoriented, non-caringand arrogant, inattentive and/or virtually“living in a world of their own.”

Fig. 15. Emotional Effects: Anxiety symptoms. Higher scores indicaterespondents were more likely to exhibit more anxiety symptoms.

Fig. 16. Emotional Effects: Social phobias. Higher scores denote thatrespondents were more likely to exhibit social phobias.

Fig. 17. Emotional Effects: Self-critical behavior. Higher scoresindicate respondents were more likely to report they “dwell on theirmistakes” or “have an inferiority complex.”

Fig. 18. Personality Measures: Family member perception ofrespondent’s cognitive state. Higher scores indicate the respondent isviewed as confused, disoriented and unable to concentrate.


As previously stated, there were nosignificant differences in measures of“withdrawal” between aided and unaidedsubjects; this finding is contrary to the lit-erature. However, family members didreport that non-users in three of five quin-tiles (1,4,5) were more introverted as evi-denced by greater likelihood of being pri-vate, passive, shy, quiet, easily embar-rassed, etc. (Fig. 19).

Moderate-to-severe hearing loss non-users (Quintiles 3-5) are shown in Fig. 20to score higher on external locus of control,meaning that they were more likely tobelieve that events external to them con-trol their lives; they feel less in control oftheir lives and at the whims of externalforces. They are also more likely to pos-sess an “active coping” personality style,meaning that they tend to do things them-selves, are hard workers and are persistentgoal-oriented individuals.

Health ImpactThe HIA-NCOA survey asked six

generic questions on self-perceptions ofhealth, prevalence of pain and the extent towhich the respondent believed that hear-ing loss impacted their general health. Inaddition, from a list of 28 health problems,respondents indicated whether they expe-rienced a specific health problem and theextent to which that problem interferedwith their activities. The overall indices andthree specific health problems (arthritis,heart problems, high blood pressure) aredocumented in Table 7.

In Fig. 21, overall assessment ofhealth (including absence of pain)would appear to decline as a function ofhearing loss, with further deteriorationof health associated with non-usage ofhearing instruments for the three mostsevere hearing loss groups (Quintiles3-5). The percent of respondents rating

their overall health as “very good” or“excellent” is shown in Fig. 22. Threeof the five hearing instrument usergroups (Quintiles 1,3,5) reported sig-nificantly better health compared totheir non-user counterparts. The low-est self-rating of overall health was thenon-user group in Quintile 5. There isno consistent evidence that hearinginstrument usage is associated withreductions in arthritis, high blood pres-sure or heart problems (Table 7).

Perceived Changes in Life Dueto Hearing Aid Use

Both respondents and their familymembers were asked to rate changesthey believed were due to the respon-dent using hearing aids. Sixteen areasof their life were queried (note: familymembers did not rate “sex life”). Bothrespondent and family member ratings

Fig. 19. Personality Measures: Family member assessment ofintroversion in respondent. High scores indicate respondent is viewed asprivate, passive, shy, quite, easily embarrassed, etc.

Fig. 20. Personality Measures: External Locus of Control.Higher scores indicate respondents “believe they have little control overthe events in their lives.”


for the five quintile groups are present-ed in Table 8 (i.e., percent of thoseresponding “somewhat” to “a lot better”improvement). In general, for nearly allquality-of-life areas assessed, theobserved improvements were positivelyrelated to degree of hearing loss. Fami-ly members in nearly every comparisonreported greater improvements in therespondent than the respondent report-ed for him/herself.

The results for the mildest loss(Quintile 1) and most severe hearingloss (Quintile 5) groups are shown inFig. 23. The top-three areas of observedimprovement for both respondents andfamily members were “relationships athome,” “feelings about self” and “lifeoverall.” The most impressive improve-ments were observed in Quintile 5: 11 of16 lifestyle areas were rated as improvedby at least 50% of the respondents or fam-ily members.

Multivariate AnalysisIn the previous tables, univariate

results have been presented for the fivecohort groups comparing users andnon-users on physical, social, emotion-al, psychological outcome measures aswell as for selected personality vari-ables. Before proceeding to the conclu-sions section, it would be useful to con-sider differences between the users andnon-users controlling for potential con-founding variables. By the term “con-founding”, we mean that, for instance,reduced depression scores in favor ofhearing instrument owners could bedue to differences in affluence andphysical health rather than hearinginstrument usage; although weacknowledge that hearing instrumentusage could also have had an impact onaffluence and physical health. What isimportant to discover is if hearinginstrument usage independently impactsthese quality-of-life factors when theeffects of potential confounding vari-ables are removed. The reader willrecall in Table 1 that there were signifi-cant differences within cohorts onincome, education, and age, as well as

physical health in Table 7.Using analysis of variance

(ANOVA), the impact of hearing instru-ment usage was evaluated on the totalsample controlling for age, hearing loss(via the FMHT), household income,physical health and education. (TheANOVA analysis was not performedwithin cohorts since the sample sizeswere not adequate within each cohort toperform a multivariate analysis of vari-ance.) Based on the results in Tables 1-7 and Figs. 1-21, it is our hypothesis thathearing instruments significantly impact-ed the following quality-of-life parameters:

Table 2: Participation in social activi-ties (Fig. 2);

Table 3: Interpersonal warmth andnegativity in relationships (Figs. 3-4);

Table 4: Communication difficulty,compensation for hearing loss, discrimi-nation against hearing-impaired (Figs.6-8);

Table 5: Anger & frustration, anxiety,depression, emotional instability, para-noia, social phobias, self-criticism and selfesteem (Figs. 10-13, 15-17);

Table 6: Cognitive abilities, introver-sion, external locus of control (Figs. 18-20);

Table 7: Overall physical health (Figs.21-22).

There were other significant findingswhich were more descriptive of hearinginstrument owners versus non-owners:lower stigma (Fig. 5), denial (Fig. 14)and higher safety concerns (Fig. 9).These latter three are more likely deter-minants of trial and usage of hearinginstruments.

After controlling for age, hearing loss(FMHT), household income, physicalhealth and education, the following fac-tors previously identified in the univari-ate analysis as significantly related tohearing instrument usage were deemedto be non-significant correlates of hear-ing aid usage: presence of anxiety symp-toms and introversion (Figs. 15 & 19).

Conclusions & DiscussionDespite the large body of evidence

on the impact of hearing loss on quality

of life, there is still a paucity of researchon the impact of hearing instruments onquality-of-life issues.

The literature presents a compellingstory for the social, psychological, cogni-tive and health effects of hearing loss (fora review of the literature [1979-1998], see“Impact of Hearing on Physical and Psy-chosocial Health” in the Nov. ‘98 HR, pgs.26-30). Impaired hearing results in dis-torted or incomplete communication,leading to greater isolation and withdraw-al and therefore lower sensory input. Inturn, the individual’s life space and sociallife become restricted.

One would logically conclude thatthis restricted lifestyle would negative-ly impact the hearing-impaired individ-ual’s psychosocial well-being. Indeed,the literature indicates that hearingloss is associated with: embarrass-ment, fatigue, irritability, tension andstress, avoidance of social activities,withdrawal from social situations,depression, negativism, danger to per-sonal safety, rejection by others,reduced general health, loneliness,social isolation, less alertness to theenvironment, impaired memory, lessadaptability to learning new tasks,paranoia, lessened ability to cope andreduced overall psychological health.In view of this, few would disagree thathearing loss per se is a serious issue.

Likewise, few would disagree thatmodern hearing instruments improvespeech intelligibility. It would seemthat, if one could improve speech intelli-gibility by correcting for impaired hear-ing, one should also observe improve-ments in the social, emotional, psycho-logical and physical functioning of theperson with the hearing loss.

� Previous Literature: To our knowl-edge, there have only been a few stud-ies to date comparing hearing instru-ment owners and non-owners. Themajority of studies have used small sam-ple sizes and are usually non-generaliz-able since they tend to confine them-selves to U.S. male veterans. Harlessand McConnell16 (1982) demonstratedthat 68 hearing instrument users had

Fig. 22. Health Status: Percent of respondents reporting that theirhealth is “very good” or “excellent.”

Fig. 21. Health Status: Overall self-assessment of health andabsence of pain. Higher scores indicate better health/less pain.


significantly higher self-concepts com-pared to a matched group of individualswho did not wear hearing instruments.Dye and Peak15 (1983) studied 58 maleveterans pre- and post-hearing instru-ment fitting and found significantimprovement on memory tests but noton paranoia or depression.

In the most rigorously controlledresearch to date, Mulrow, Aguilar andEndicott18 (1990) studied 122 male vet-erans and 72 patients from primary careclinics. Half were randomly chosen andfit with hearing instruments while theother half were not. After four months,the researchers found significantimprovements in the hearing instru-ment wearers (compared to the controlgroup) on emotional and social effectsof hearing handicap (as measured bythe Hearing Handicap Inventory for theElderly), perceived communication diffi-culties (Quantified Denver Scale ofCommunication Function), cognitivefunction (Short Portable Mental StatusQuestionnaire) and depression (Geri-atric Depression Scale or GDS), but notSelf-Evaluation of Life Functioning.Additionally, the same researchers in afollow-up study published in 1992demonstrated that the quality of life

changes were sustainable over at least ayear.19

In a study of 251 subjects comprisedof normal-hearing elderly individualswith hearing instruments and individu-als with unaided hearing loss, Bridgesand Bentler12 (1998) determined thathearing instrument wearers had lowerdepression (GDS scores) and higherquality-of-life (Satisfaction with LifeScale) scores compared to their unaidedcounterparts. Additionally, in a pre-poststudy of 20 subjects, Crandell14 (1998)demonstrated after three months ofhearing instrument use that functionalhealth status (Sickness Impact Profile)improved significantly for hearinginstrument wearers.

� Present Study ’s Findings: Theresults of the study presented in thisissue of The Hearing Review, in theauthors’ opinions, are unequivocal andare corroborated by the smaller correla-tional and experimental studies. Hear-ing instruments are clearly associatedwith impressive improvements in thesocial, emotional, psychological andphysical well-being of people with hear-ing loss in all hearing loss categoriesfrom mild to severe. As such, these find-ings provide strong evidence for the

“value” of hearing instruments inimproving the quality of life of peoplewith hearing loss. Specifically, hearinginstrument usage is positively related tothe following quality-of-life issues:

• Greater earning power (especiallythe more severe hearing losses);

• Improved interpersonal relation-ships (especially for mild-to-moder-ate losses), including greater inti-macy and lessening of negative dys-functional communication;

• Reduction in discrimination towardthe person with the hearing loss;

• Reduction in difficulty associatedwith communication (primarilysevere to profound hearing losses);

• Reduction in hearing loss compen-sation behaviors;

• Reduction in anger and frustration;• Reduction in the incidence of

depression and depressive symp-toms;

• Enhanced emotional stability;• Reduction in paranoid feelings;• Reduced anxiety symptoms (howev-

er, this could be related to lowerincome and reduced physical healthstatus, which are also correlates ofhearing aid usage);

• Reduced social phobias (primarilyseverely impaired subjects);

• Improved belief that the subject is incontrol of their lives (locus of con-trol);

• Reduced self-criticism;• Improved cognitive functioning

(primarily severe-to-profound hear-ing loss);

• Improved health status and lessincidence of pain, and

• Enhanced group social activity.Secondly, in this study, both respon-

dents and their family members wereasked to independently rate the extentto which they believe their lives wereimproved specifically due to hearinginstruments. Both mild and serious hear-ing loss groups reported significantimprovements in nearly every area mea-sured:

• Relationships at home and with thefamily;

• Feelings about self;• Life overall;• Mental health;• Social life;• Emotional health, and• Physical health.Given that this is an observational

study—that is, we compared hearingloss subjects both aided and unaided—we cannot, of course, say that hearinginstrument usage “caused” all thesepositive quality-of-life improvements. Infact, as one esteemed observer statedat the EHIMA presentation, “Perhapsonly emotionally stable subjects pur-chase hearing aids, and thus, maybethe best strategy is to get all unaided

Fig. 23. Positive Changes and Reported Benefits: Percent of hearing instrumentowners and their family members reporting improvement in their quality of life in 16 areas dueto hearing instruments. The first bar is the mildest hearing loss group (Quintile 1, light color),while the second bar within each quality-of-life area is the most severe hearing loss group(Quintile 5, darker bar). In nearly all cases, the family members report greater improvementsdue to hearing instruments than the hearing instrument wearers.


hearing-impaired people into therapy.”We think our answer to this is, “Wewould first have to fit them with hear-ing aids to improve their speech intelli-gibility so they could hear the thera-pist!” None of the literature suggeststhat those who are inclined to becomehearing instrument users are signifi-cantly more emotionally, socially ormentally mature than their unaidedcounterparts. Certainly, the Mulrow etal.18 and Crandell14 studies have demon-strated causation due to hearing instru-ment usage. Short of stating definitecausality, the evidence is quite com-pelling and perhaps suggestive ofcausality for the following reasons:

• The sample, the largest of its kind,is nationally representative of hear-ing loss subjects ages 50 and above.Thus, we need not be concernedwith spurious findings due to sam-pling methodology;

• Many of the findings held upacross all hearing loss quintiles,from mild to profound;

• The specific findings were corrob-orated within the study. That is,significant differences betweenusers and non-users were noted.Secondly, at the end of the survey,respondents and their family mem-bers were asked to specificallyindicate if their life was improvedas a result of wearing hearinginstruments in 16 quality-of-lifeareas. Both respondents and theirfamily members indicated signifi-cant benefit due to hearing instru-ments in most areas measured;

• The differential efficacy betweenthe 16 quality-of-life parametersnoted by respondents and theirfamily members (low of 4% to highof 74% improvements) indicatesthat a positive halo or acquies-cence did not exist in this sampleof respondents;

• The survey findings are consistentwith other correlational and (espe-cially) randomized control studies,and pre-post hearing aid fittingstudies among smaller, more nar-rowly defined samples;

• The findings are consistent withthe literature on factors impactinghearing loss (i.e., the theoreticalimprovements which should occurif hearing loss is alleviated);

• The findings are consistent withthe observations of clinicians anddispensers of hearing aids.

A Call to Action� Allying with Medical Professionals:

In his speech to the media last summer,James Firman, PhD, said, “This studydebunks the myth that untreated hear-ing loss in older persons is a harmlesscondition.” In focus groups with physi-

cians, the prevalent view is that hearingloss is “only” a quality-of-life issue. Theauthors would agree with this statementif the definition of “quality of life” was“greater enjoyment of music” or somesimilar measure. However, the literatureand this study clearly demonstrate thathearing loss is associated with physical,emotional, mental and social well-being.Depression, anxiety, emotional instabili-ty, phobias, withdrawal, isolation, less-ened health status, lower self esteem,etc, are not “just quality of life issues.”For many people, uncorrected hearingloss is a serious health issue, if not a “lifeor death” issue.

This study challenges every segmentof the hearing care field to intensify inter-action and communication with the med-ical community. We need to do every-thing possible to help physicians recog-nize hearing loss as an important healthissue. Articles need to be published inmedical journals that report the resultsof this study, and more editorial contentneeds to be created about hearing lossand health for other physician-directedinformational sources. Previous efforts,which were proven to be successful,need to be resurrected to help physi-cians—from those still in school to thosein practice—to incorporate basic hearingscreening into routine, general physicalexams for all adults. All hearing-relatedorganizations must communicate notonly with family physicians but also withgerontologists, with specialists in otherage-related medical conditions and withother medical and allied health special-ties including psychology, social workand optometry. Hearing care profession-als and the hearing care industry must bethe ones who ensure that hearing loss isrecognized not only for its own treatment,but also as a potential contributing factorto the successful resolution of other med-ical and psychological conditions.

Previous HIA consumer research hasdocumented the inclination of peoplewho have a hearing loss to view theirproblem as a medical issue. Consumersbelieve that their physicians should be thesource of guidance for hearing problems,like other health issues, so the hearingindustry must ensure that physicians arefully prepared to shoulder this responsi-bility. Physicians should be made awareof the scope and incidence of the prob-lem and the positive health benefits oftreatment with hearing instruments.

� Preparing a New Message for a NewCustomer in a New Millennium: This studyalso demonstrates, possibly for the firsttime, that individuals with even a mildhearing loss can experience dramaticimprovements in their quality of life. Thisfinding is significant because one impor-tant challenge for the hearing health carefield is to demonstrate to Baby-Boomerswith emerging hearing losses that the

hearing care community offers somethingof value early on in their lives and that theydo not need to wait until retirement toreceive help for a hearing problem. Hear-ing is not only an issue for the elderly; it isa cradle-to-grave health and quality-of-lifeissue confronting all age groups.

The hearing industry has concentrat-ed historically on demonstrating to con-sumers that amplification can improvespeech intelligibility, or certain productscan help hide hearing loss with “invisible”aids, or a certain advanced technologyoffers improved functionality. These bene-fits are not enough for most consumers;most consumers simply do not under-stand the connection between the hearingfeatures that are marketed and the impacton their daily life. As Bridges andBentler12 recently stated, “It is up to thehearing care community to demonstratethat hearing aids are necessary, not onlyfor improved communication, but also forenhanced sense of well-being.” Our think-ing needs to change from “we sell hearingaids,” or “we will help you hide your hear-ing loss with CICs” or “we improvespeech intelligibility” to “we have some-thing that will change your life,” “we havesomething that will improve your relation-ships,” or “we have something that hasthe potential to improve intimacy (Viagrafor the ears!), reduce stress, improve yourself-concept, make you feel better aboutyourself and the world, give you confi-dence, improve your social life, improveyour mental function and environmentalvigilance...” As demonstrated, this list ofpotential benefits could go on and on. Thepoint is that the potential messages on thevalue of hearing care services and amplifi-cation are almost infinite once the focus ison the practical benefits offered to peopleand their families.

The Boomers, for themselves and fortheir families, are impatient with anythingthat is less than it might be, and thatincludes all aspects of physical well-being. They are reportedly the most will-ing, as a group, to spend discretionaryfunds on health improvements, as evi-denced by large surges in the use of vita-mins and herbal supplements, in thegrowth of elective cosmetic surgery pro-cedures, and the replacement of contactlens use by refractive surgery. The hear-ing industry must begin to talk with BabyBoomers about hearing health and itsimpact on the psychological, emotionaland social aspects of their lives. Hearingcare professionals, as well as the hearingindustry, must aggressively seek commu-nication channels with this 78-million-peo-ple segment of society. New messagesneed to be created that complementphysicians’ input, and we need to carrythese messages in contemporary ways.This includes messages featured in themyriad of health, wellness and preventionpublications on the market today and


within the mass media discussions onhealth issues of all kinds—and perhapsmost importantly on the Internet.

If changes can be made to the mes-sages about hearing loss and its prima-ry treatment, hearing instruments, a dia-logue can beginwith people whoneed these prod-ucts and servicesbut who, until now,may not have rec-ognized their prob-lem or compre-hended that hear-ing instrumentsconstitute the bestsolution for thatproblem.

In essence, it istime for hearingcare to repositionitself for the nextmillennium. Thereare millions ofpotential cus-tomers (and theirphysicians) whoare not yet awareof the value that amplification and hear-ing care services deliver. And they willnot know unless the hearing care com-munity shares the secret. In the decadeto come, a concerted effort needs to bemade by hearing care professionals andthe hearing industry to work together tofundamentally change society’s percep-tion of the stakes involved in treating(and in not treating) hearing loss. �

References1. National Council on the Aging (NCOA): The

Impact of Untreated Hearing Loss in Older Ameri-cans. Conducted by the Seniors Research Group.Supported through a grant from the Hearing Indus-tries Association. Preliminary report, 12/28/98.

2. Kochkin S: Quantifying the Obvious: The Impact ofUntreated Hearing Loss on Quality of Life, KnowlesElectronics, Itasca, IL: May 1999.

3. Kirkwood D: Major survey documents negativeimpact of untreated hearing loss on quality of life.

Hear Jour 1990: 52 (7): 32-40.4. Strom K: HIA-NCOA Project documents benefit of

hearing instruments. Hearing Review 1999; 6 (7):8-10.

5. Kochkin S: MarkeTrak V: “Baby Boomers” spurgrowth in potential market, but penetration ratedeclines. Hear Jour 1999; 52 (1): 33-48.

6. Kochkin S: MarkeTrakV: Customer satisfac-tion revisited. HearJour: in press.

7. Kochkin S. MarkeTrakV: Hearing aid industrymarket tracking survey.HIA Marketing Semi-nar, Minneapolis, June23, 1999.

8. Kochkin S: MarkeTrakV survey (unpublished),November 1998. Mar-keTrak IV survey.(unpublished), Novem-ber 1994. KnowlesElectronics, Inc., Itasca,IL.

9. Kochkin S & Calder B:Project Pygmalion.Knowles Publication,Knowles Publication,Itasca, IL: Sept 1997.

10. Bess FH, Lichtenstein MJ, Logan SA, Berger MC &Nelson E: Hearing Loss as a determinant of func-tion in the elderly. Jour Amer Geriatrics Soc 1989;37:123-128.

11. Bess F, Lichtenstein M, Logan S: Making hearingimpairment functionally relevant: Linkages withhearing disability and handicap. Acta Otolaryn1991; 476 (suppl): 39-44.

12. Bridges J & Bentler R: Relating hearing aid use towell-being among older adults. Hear Jour 1998;51(7):39-44.

13. Carabellese C, Appollonio I, Rozzini R, BianchettiA, Frisoni GB, Frattola L & Trabucchi M: Sensoryimpairment and quality of life in a communityelderly population. Jou r Amer Geriatrics Soc1993; 41:401-407.

14. Crandell C: Hearing aids: Their effects on function-al health status. Hear Jour 1998; 51(2):2-6.

15. Dye C & Peak M: Influence on amplification on thepsychological functioning of older adults with neu-rosensory hearing loss. Jour Acad Rehab Aud

1983; 16 :210-220.16. Harless E & McConnell F: Effects of hearing aid

use on self concept in older persons. Jour Sp HearDisorders 1982; 47:305-309.

17. Mulrow CD, Aguilar C, Endicott JE, Tuley MR,Velez R, Charlip WS, Rhodes MC, Hill JA & DeNi-no A: Quality of life changes and hearing impair-ment. Ann Internal Med 1990; 3:188-194.

18. Mulrow CD, Aguilar CC, Endicott JE, Valez R,Tuley MR, Charlip WS & Hill JA: Associationbetween hearing impairment and quality of life ofElderly Individuals. Jour Amer Geriatrics Soc1990; 38:45-50.

19. Mulrow C, Tuley M & Aguilar C: Sustained bene-fits of hearing aids. Jour Speech Hear Res 1992;35: 1402-1405.

20. Oyer H & Oyer E: Social Consequences of hear-ing loss for the elderly. Allied Health and BehavSciences 1979; Vol. 2(2):123-138.

21. Thomas A & Gilhome Herbst K: Social and psy-chological implications of acquired deafness foradults of employment age. Brit Jour of Aud 1980;14:76-85.

22. Wienstein B & Ventry I: Hearing impairment andsocial isolation in the elderly. Jour Speech Hear Res1982; 25:593- 599.

23. World Health Organization (WHO): CompositeInternational Diagnostic Interview (CIDI, Version1.1). Geneva: WHO, 1990.

24. Hirschfeld RM: A measure of interpersonal depen-dency. Jour Personality Assessment 1977; 41:610-618.

25. James SA, Hartnett SA & Kalsbeek WD: John Hen-ryism and blood pressure differences among Blackmen. Jour of Behav Med 1983; 6: 259-278.

26. Levenson H: Multidimensional locus of control inpsychiatric patients. Jour Consulting & Clin Psychol1973; 41, 397-404.

27. Rosenberg M: Society and the Adolescent Self-Image. Princeton, NJ: Princeton Univ Press, 1965.

28. Koike K, Hurst M & Westmore S: Correlationbetween the American Academy of Otolaryngolo-gy—Head and Neck Surgery five minute hearingtest and standard audiologic data. Otolaryngology -Head and Neck Surgery 1994; 111 (5): 625-632.

Correspondence can be addressed to HR orSergei Kochkin, PhD, Knowles ElectronicsInc., 1151 Maplewood Dr., Itasca, IL 60143.

The literature and this studyclearly demonstrate that hearingloss is associated with physical,emotional, mental and socialwell-being. Depression, anxiety,emotional instability, phobias,withdrawal, isolation, lessenedhealth status and lessened self-esteem are not “just quality oflife” issues. For many people,uncorrected hearing loss is aserious “life or death” issue.

quantifying the obvious: the impact of hearing instruments...

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