The Association Between Hearing Status and
Psychosocial Health Before the Age of 70 Years: Results
From an Internet-Based National Survey on Hearing
Jan H. Smit,
Pieter D. Bezemer,
Johannes H. M. van Beek,
Joost M. Festen,
and Sophia E. Kramer
Objective: There is a substantial lack of knowledge of the impact of
reduced hearing on psychosocial functioning in adults younger than 70
yr. The aim of this study was to examine the association between
hearing status and psychosocial health in adults aged between 18 and
Design: This was a cross-sectional cohort study. Baseline data of the
National Longitudinal Study on Hearing are analyzed using regression
models. The cohort consisted of 1511 participants. Hearing status was
determined using the National Hearing test, a recently launched speech-
in-noise screening test over the Internet. We assessed self-reported
psychosocial health using a set of online questionnaires.
Results: Adjusting for confounding variables, significant adverse asso-
ciations between hearing status and distress, somatization, depression,
and loneliness are found. For every decibel signal to noise ratio (dB
SNR) reduction of hearing status, both the distress and somatization
scores increased by 2% [distress: b⫽0.02, 95% confidence interval
(CI) ⫽0.00 to 0.03, p⫽0.03; somatization: b⫽0.02, 95% CI ⫽0.01
to 0.04, p⬍0.001]. The odds for developing moderate or severe
depression increase by 5% for every dB SNR reduction in hearing (odds
ratio ⫽1.05, 95% CI ⫽1.00 to 1.09, p⫽0.03). The odds for
developing severe or very severe loneliness significantly increase by 7%
for every dB SNR reduction in hearing (odds ratio ⫽1.07, 95% CI ⫽
1.02 to 1.12, p⫽0.004). Different age groups exhibit different
associations between hearing status and psychosocial health, with
loneliness being an issue particularly in the youngest age group (18 to
30 yr). In the group of middle-aged adults (40 to 50 yr), the number of
significant associations is highest.
Conclusions: Hearing status is negatively associated with higher dis-
tress, depression, somatization, and loneliness in young and middle-
aged adults. The associations are different in different age groups. The
findings underline the need to seriously address the adverse effects of
limited hearing among young and middle-aged adults both in future
research and in clinical practice.
(Ear & Hearing 2009;30;302–312)
Hearing impairment is one of the most frequent chronic
conditions in human populations. More than 250 million
people in the world are affected by hearing loss (Mathers et al.
2003). Despite the fact that the majority of persons with
hearing impairments are older than 70 yr, a considerable
number of younger individuals are experiencing hearing prob-
lems. Community surveys in different countries worldwide
revealed that the prevalence of hearing impairment in the adult
population (18 to 70 yr) varies between 10 and 20% (Davis
1989; Hannaford et al. 2005; Karlsmose et al. 2000; Mathers
et al. 2003). Prevalence rates do depend on the tests and the
criteria applied (Duivestijn et al. 1999). In the above studies,
pure-tone audiometry or self-report was used. Davis (1989)
found the prevalence of self-reported bilateral hearing impair-
ment in a quiet environment to be lower than the prevalence
when using pure-tone audiometry (10% versus 16%). Accord-
ing to Karlsmose et al. (2000), self-report of any difficulties
with hearing led to a higher prevalence of hearing impairment
(14.8%) compared with pure-tone audiometry (11.6%). When
specifically assessing difficulties after conversations in back-
ground noise, rates are even higher. For example, Hannaford et
al. (2005), reported a prevalence rate of 21.1% when assessing
difficulties in after conversations in background noise com-
pared with a prevalence rate of 18.3% when “any difficulty
with hearing” was assessed.
Hearing impairment inevitably affects health-related quality
of life (Chia et al. 2007; Dalton et al. 2003; Lee et al. 1999;
Ringdahl & Grimby 2000). In particular, psychological, social,
and emotional functioning seems to be negatively influenced,
rather than mobility and activities of daily living (Carabellese
et al. 1993). Psychosocial variables found to be related to
hearing impairment are depression (Cacciatore et al. 1999;
Kramer et al. 2002; Strawbridge et al. 2000), loneliness
(Fellinger et al. 2007; Hawthorne 2008; Knutson & Lansing
1990; Kramer et al. 2002), anxiety, distress, somatization (i.e.,
the tendency to experience somatic symptoms in response to
psychological stress, to attribute them to physical illness, and to
seek medical help for them; Eriksson-Mangold & Carlsson
1991), and poorer social functioning (Cacciatore et al. 1999;
Mulrow et al. 1990; Ringdahl & Grimby 2000). However, the
vast majority of studies focusing on the relationship between
hearing impairment and psychosocial health included samples
of elderly people (Table 1). There is a substantial lack of
knowledge about the impact of reduced hearing on psychoso-
cial functioning in younger adults. People in different age
groups are likely to emphasize psychosocial issues differently
as lifestyles, occupational obligations and circumstances, com-
munication needs, and listening conditions may differ. To the
best of our knowledge, only a small number of quantitative
studies in the international literature focused on younger age
groups (Table 1). Two were based on relatively small sample
sizes (Hallam et al. 2006; Knutson & Lansing 1990). Tambs
(2004) studied a large cohort of ⬎50,000 subjects of 20 yr and
over and found younger (20 to 44 yr) and middle-aged
participants (44 to 65 yr) reporting higher levels of anxiety and
depression, lower self-esteem, and subjective well-being com-
pared with normally hearing peers. Moreover, among young
Clinical Epidemiology and
EMGO Institute, VU University Medical Centre, Amster-
dam, The Netherlands.
0196/0202/09/3003-0302/0 • Ear & Hearing • Copyright © 2009 by Lippincott Williams & Wilkins • Printed in the U.S.A.
TABLE 1. Overview of studies on the association between hearing and psychosocial health, showing the characteristics of the
population, the method of determining hearing status, psychosocial health variables examined, and results of the study
Hearing status Outcome measures ResultsN Mean age (range) (yr)
Cacciatore et al.
1332 74.2 (65–96) Self-report Depression Adverse correlation between hearing status
and depression score
Carabellese et al.
1191 – (70 –75) Free field
Depression Adverse association between hearing sta-
tus and depression (compared with per-
sons with normal hearing and vision)
Chia et al. (2007) 2431 67.0 (49⫹) Audiometry Health-related QOL Adverse association between hearing sta-
tus and physical and mental QOL
Dalton et al. (2003) 2688 69 (53–97) Audiometry Social functioning;
Individuals with mild or moderate hearing
loss were more likely to report lower
mental health and social functioning
48 68.8 (55–74) Audiometry;
Adverse correlation between perceived
hearing disability/handicap and anxiety
and somatization; no correlation with de-
Fellinger et al. (2007) 373 — Self-report QOL; distress; anxiety;
Higher distress, somatization, and depres-
sion and lower QOL for individuals with
Hallam et al. (2006) 122 54.4; 51.4 (21–80) Self-report Depression; anxiety;
Depression significantly different from norm
population; subgroup with acquired pro-
found hearing loss was severely dis-
tressed and handicapped
Hawthorne (2008) 3015 45.3 (15– 60⫹) Self-report Loneliness Hearing impairment was significantly asso-
ciated with higher odds for social
Knutson and Lansing
27 49.1 (22– 68) Self-report Depression; loneliness
Group mean scores were in the normal
range, but many participants reported
mild to moderate depression; candidates
for cochlear implantation were similar to
the loneliest group for which the UCLA
loneliness scale was used
Kramer et al. (2002) 3107 – (55–85) Self-report Depression; loneliness;
More depressive symptoms, lower self-
efficacy, and more feelings of loneliness
for individuals with poor hearing
Lee et al. (1999) 7320 77.3 (70⫹) Self-report Overall functioning Adverse correlation between hearing status
and overall functioning
Mulrow et al. (1990) 472 72 (HI) 69 (NH) Audiometry Depression No association between hearing status and
depression after adjustment for age,
education, visual acuity, and number of
Naramura et al. (1999) 747 80.2 (65–94) Audiometry Depression Adverse single (but not multiple) correlation
between moderate to severe hearing im-
pairment and depression
Tambs (2004) 50,398 50.2 (20–101) Audiometry Depression; anxiety;
Adverse association between hearing sta-
tus and anxiety, depression, self-esteem,
and well-being among young and mid-
dle-aged persons; no such association
found for older persons
Ringdahl and Grimby
311 66 Audiometry Social isolation;
More social isolation and emotional reac-
tions in individuals with poor hearing
Strawbridge et al.
2461 65 (50 –102) Self-report Depression; social
Adverse association between hearing sta-
tus and depression and loneliness
Wallhagen (1996) 356 72 (65–95) Self-report Depression Higher depression scores in individuals
with poor hearing status
QOL, quality of life.
NACHTEGAAL ET AL. / EAR & HEARING, VOL. 30, NO. 3, 302–312 303
and middle-aged adults with a hearing impairment, the impact on
psychosocial health was larger than among the oldest adults (older
than 65 yr) with a hearing impairment. Earlier, Erdman and
Demorest (1998) mentioned a possible difference in the adjust-
ment to hearing impairment for different age groups, with adjust-
ment being poorer among the youngest and oldest individuals.
Another issue that needs consideration within this context is
the way hearing status was determined. Although some studies
used standardized audiometric techniques or functional mea-
sures (e.g., free-field whispered voice test; Carabellese et al.
1993), the majority of investigations relied on self-report.
Several studies have shown that self-report is a useful and
satisfactory method to assess hearing impairment and activity
limitations (Kramer et al. 1996; Lutman et al. 1987;
Sindhusake et al. 2001). However, people in different age
groups are likely to assess their hearing problems differently,
with older people being less likely to self-report activity
limitations compared with younger respondents (Gatehouse
1990; Lutman et al. 1987; Smits et al. 2006a).
Although pure-tone audiometry still serves as the gold
standard for diagnostic purposes in audiological practice, it has
been found to be an inaccurate predictor of the reduced ability
to understand speech in adverse listening circumstances (Hout-
gast & Festen 2008; Kramer et al. 1996), a limitation most
frequently experienced among people with hearing impair-
ment. This reduced ability to understand speech in adverse
listening circumstances is one of the primary and most limiting
manifestations of hearing impairment (King et al. 1992; Plomp
& Mimpen 1979).
A performance test offering a direct measure of a person’s
ability to understand speech in adverse listening conditions is a
speech-in-noise test (Nilson et al. 1994; Smits et al. 2004). It
provides a more realistic estimation of the perceived limitations
in hearing because it measures how well a person understands
speech in the presence of noise. Recently, a functional fully
automatic speech-in-noise screening test for use by telephone
and over the Internet was developed (Smits et al. 2006b). It is
a self-test, measuring the speech reception threshold (SRT
noise, using number of triplets presented according to an
adaptive procedure. The test is referred to as the National
Hearing test and is implemented in The Netherlands and United
Kingdom and will be implemented in other countries soon.
With the present cross-sectional study, we aimed to examine
the relationship between scores on the National Hearing test
and self-reported psychosocial functioning in a large cohort of
young and middle-aged adults (younger than 70 yr) in The
Netherlands. We also investigated whether the association
differed for different age groups.
MATERIALS AND METHODS
Data for this study were derived from the National Longi-
tudinal Study on Hearing (NL-SH) conducted in The Nether-
lands. The NL-SH is an ongoing prospective cohort study
examining the relationship between hearing impairment and
several domains in life. The NL-SH is conducted over the
Internet and uses a website to enroll and inform the participants
to collect data (www.hooronderzoek.nl). People are invited to
participate in the NL-SH through advertisements and flyers
distributed at audiological centers and hearing aid dispensers
throughout The Netherlands. Eligible participants are adults
between 18 and 70 yr of age. Both normally hearing and
hearing-impaired persons are invited to participate.
Each person who is interested to participate in the NL-SH is
instructed to first perform the National Hearing test on the
Internet (details provided in the Hearing Status section). After
finishing this test, potential participants are redirected to the
NL-SH website where they can complete their subscription.
The cross-sectional data analyzed in the present study are
the baseline data of the NL-SH collected in the period from
November 2006 to November 2007. After enrollment, the
participants received an e-mail with a link to the set of online
questionnaires. An e-mail reminder was sent to those who did
not complete the questionnaires within 1 wk. Participants who
did not respond within a month received a letter by regular
mail. The study was approved by the Medical Ethics Commit-
tee of the VU University medical center.
Hearing status •Hearing status was determined using the
National Hearing test, an adaptive speech-in-noise screening
test (Smits et al. 2004). The test uses digit triplets (e.g., 6 –2–5)
that are presented against a background of masking noise,
according to an adaptive (one-up, one-down) procedure. A total
of 23 triplets are presented. The speech reception threshold
corresponds to 50% intelligibility and is calculated by taking
the average signal to noise ratio (SNR) of the last 20 presen-
tations. The SNR (outcome of the test) is further referred to as
. In general, SRT
values range between approxi-
mately ⫺10 (the best normally hearing individual) to ⫹4dB
SNR (Smits et al. 2006b).
Initially, the test was developed for delivery by tele-
phone. However, to provide access over the Internet, an
identical version with the same stimuli was implemented on
the Internet (Smits et al. 2006b) (www.hoortest.nl). For the
Internet application, the telephone and telephone network
was simulated by filtering, compression, and decompression
of the original speech and noise files (Smits & Houtgast
2006). The files were then compressed to MP3 format, and
a Macromedia Flash Player (Macromedia, Inc., San Fran-
cisco, CA) web application was designed. Also, the test
procedure over the Internet was similar to that of the
Once at the website, subjects received instructions to
perform the test in a quiet environment, to use headphones
instead of speakers, and if using speakers to do so only in a
quiet environment. To continue, they had to click on the
button “headphones” or “speakers.” Then, a triplet was
presented repeatedly, and subjects were instructed to use
their PC’s volume control or the slider on the screen to
adjust the volume to a level at which they could understand
the triplet clearly. An explanation of the test procedure
followed, and the participant could start the test. The
listener had to respond by entering the digits on the
computer keyboard or by clicking the digits on the screen
with the mouse (Smits et al. 2006b).
Comparing the telephone and Internet version of the test,
Smits et al. (2006b) concluded that both versions are equally
NACHTEGAAL ET AL. / EAR & HEARING, VOL. 30, NO. 3, 302–312304
feasible and reliable, except that older people prefer deliv-
ery by telephone.
Smits et al. (2004) determined sensitivity and specificity
of the test for an adult population. The Dutch speech-in-
noise sentences test using headphones was taken as the gold
standard. A sensitivity of 0.91 and a specificity of 0.93 were
found (Smits et al. 2004). The test correlates highly (r⫽
0.87) with the standard speech-in-noise sentences test as
used in the laboratory and clinical practice (Smits et al.
2004). Correlations with average pure tone thresholds at 0.5,
1.0, and 2.0 kHz was 0.73, at 0.5, 1.0, 2.0, and 4.0 kHz the
correlation was 0.77 (Smits et al. 2004). The National
Hearing test scores were classified into three categories
representing good (SRT
⬍⫺5.5 dB), insufficient (⫺5.5 ⱕ
ⱕ⫺2.8), and poor (SRT
⬎⫺2.8 dB) hearing.
Test-retest data were available for 721 participants who
accomplished the Internet version of the National Hearing
test twice within 1 yr. The test-retest correlation was r⫽
Psychosocial health status •Psychosocial health status was
assessed using three questionnaires covering six variables
(distress, depression, anxiety, somatization, loneliness, and
self-efficacy). Each of the questionnaires is described below.
a. Four-Dimensional Symptom Questionnaire (Terluin
et al. 2006).
The 50-item Four-Dimensional Symptom Question-
naire covering four subscales (Terluin et al. 2006) was
used to assess distress, depression, anxiety, and som-
atization. The Four-Dimensional Symptom Question-
naire has proved to be a reliable and valid instrument
for use in The Netherlands with high internal consis-
tency (Cronbach’s alpha of the different scales vary-
ing from 0.84 to 0.94). It distinguishes nonspecific
general distress from depression, anxiety, and soma-
tization. Each item has five response choices: “no,”
“sometimes,” “regularly,” “often,” and “very often or
constantly.” Answers were recoded into 0 (no), 1
(sometimes), and 2 (remaining categories). All men-
tioned cutoff scores were recommended by the test
Distress: This is defined as “the direct manifestation
of the effort people must exert to maintain their
psychosocial homeostasis and social functioning
when confronted with stress” (Terluin et al. 2006).
Symptoms are worry, tension, and poor concentration.
An item example is “During the past week, did you
feel easily irritated?” Scores on the distress scale (16
items) were summed when at least 10 items were
completed. Summed scores higher than 9 indicated
moderately elevated distress; a score higher than 20
indicated strongly elevated distress (Terluin et al.
Depression: The depression scale (6 items) measures
depressive thoughts (e.g., During the past week, did
you feel that everything is meaningless?). Scores were
summed when at least four items were completed.
Summed scores higher than 2 indicated moderately
elevated depression; a score higher than 5 indicated
highly elevated depression (Terluin et al. 2006).
Anxiety: Irrational fears, anxiety, and avoidance be-
havior are included in the anxiety scale (12 items)
(e.g., During the past week, did you suffer from
trembling when with other people?). Scores were
summed when at least eight items were completed.
Summed scores higher than 8 indicated moderately
elevated anxiety; scores higher than 12 indicated
highly elevated anxiety (Terluin et al. 2006).
Somatization: It is defined as the tendency to experi-
ence somatic symptoms in response to psychological
stress, to attribute them to physical illness, and to seek
medical help for them (Lipowski 1988) (e.g., During
the past week, did you suffer from nausea or an upset
stomach?). Summing occurred when at least 9 (of 16)
items were completed. A summed score higher than
10 indicated moderately elevated somatization; a
score higher than 20 indicated highly elevated soma-
tization (Terluin et al. 2006).
b. Loneliness Scale (De Jong Gierveld & Kamphuis 1985).
Loneliness was measured using the 11-item Loneli-
ness Scale. It is a widely used robust, reliable, and
valid instrument (Van Tilburg & De Leeuw 1991).
Each item has five answer categories: no!, no, more,
or less, yes, or yes!
Loneliness refers to a lack of (quality of) certain
relationships, e.g., “I miss having a really close
friend.” Answers on the five-point scale were recoded
into 1, indicating loneliness (no!, no, or more or less
on a negatively formulated item; more or less, yes, or
yes! on a positively formulated item) or 0 (no loneli-
ness). Scores were summed when at least 10 items
were completed. A score from 9 or 10 indicated
severe loneliness, whereas a summed score of 11
indicated very severe loneliness (Van Tilburg & De
Jong Gierveld 1999).
c. The 12-item General Self-Efficacy Scale.
The General Self-Efficacy Scale measures the general
expectation of self-efficacy. It includes 12 statements
with a five-point response scale. Bosscher and Smit
(1998) showed that the General Self-Efficacy Scale is
a reliable and a valid instrument for use in The
Self-efficacy: It is defined as “the belief of a person in
his/her ability to organize and execute behaviors
necessary to produce attainments” (Bosscher & Smit
1998). An item example is, “If something looks too
complicated, I will not even bother to try it.” Re-
sponse categories ranged from 1 (I totally agree) to 5
(I totally disagree) with summed scores ranging from
12 (most negative) to 60 (most positive). Scores were
summed when at least nine items were completed.
NACHTEGAAL ET AL. / EAR & HEARING, VOL. 30, NO. 3, 302–312 305
The set of questionnaires was sent to 1796 people, of
whom 1588 (88.4%) returned the questionnaires partially or
totally completed. To test potential differences between
responders and nonresponders (11.6%) a Chi-square test
(gender) and independent ttests (hearing status, age) were
conducted. Nonresponders were significantly younger
(mean age: 42.05 yr, SD: 13.7 yr) (t⫽⫺4.03, p⬍0.001)
than responders (mean age: 46.3 yr, SD: 12.5 yr), but no
significant differences in gender and hearing status were
found. Of the 1588 participants who responded, data from
1511 participants (546 men and 965 women) could be
included in the analyses. Their ages ranged from 18 to 70 yr
(mean: 46.3 yr, SD: 12.5 yr). In all, 355 participants (23.5%)
reported to have hearing aids.
As demographic and socioeconomic variables are known to
be associated with psychosocial health (Koster et al. 2006;
Palinkas et al. 1990; Wang et al. 2005), age, gender, marital
status (married or not), educational level, living arrangements,
and income were adopted as covariates to control for confound-
Educational level was determined by asking the participants
to report their highest completed education. Three levels were
distinguished: low (no finished elementary school to lower
vocational), mid (general intermediate to general secondary),
and high education (higher vocational to postacademic).
Living arrangement was classified into two categories:
living alone (1) or living with a partner or others (2).
Income was measured by asking the participants to choose
their gross monthly income category: low (⬍€1050), mid
(between €1050 and €2550), high (⬎€2550) income, or un-
known (don’t know; don’t want to report).
All analyses were conducted using SPSS version 15.0.
Linear regression analyses were used to examine the unad-
justed associations between hearing status and the psychosocial
variables (model 1), followed by multiple linear regression
analyses adjusting for all potential confounders (model 2). The
analyses were run with (log-transformed) distress, (log-trans-
formed) somatization, and self-efficacy successively as depen-
dent variables. The National Hearing test score was entered as
a continuous independent variable in all analyses. Because the
distribution of the loneliness, depression, and anxiety scores
was extremely positively skewed, these variables were dichot-
omized into 0 (no loneliness, depression, or anxiety) and 1
(moderately to severely elevated levels) and analyzed using
Interaction effect among the National Hearing test score
and age was examined by entering the product of the
Fig. 1. Histogram of National Hearing test scores. Doted lines mark the cutoff point for good, insufficient, and poor hearing.
NACHTEGAAL ET AL. / EAR & HEARING, VOL. 30, NO. 3, 302–312306
National Hearing test score and age, and those variables
separately in the regression models. Similarly, the interac-
tion between the National Hearing test score and gender was
examined. No significant interaction with gender was found.
However, the interaction of age (stratified into decades)
with the National Hearing test score seemed to be significant
in the models predicting self-efficacy, loneliness, and de-
pression. Hence, regression analyses were run for each of
the five age strata (18 to 29, 30 to 39, 40 to 49, 50 to 59, and
60 to 70 yr) separately to examine whether different age
groups exhibited different associations between hearing
status and psychosocial health.
Furthermore, we examined whether the association between
hearing status and psychosocial health was influenced by the
way participants performed the National Hearing test. Despite
the instruction to use headphones instead of speakers during the
test, a considerable number of participants did not use head-
phones (headphones, 35.6%; speakers, 64.4%). Therefore,
confounding and interaction effects of headphone/speaker use
Missing values •Item nonresponse rates were ⬍2% for all
items in the questionnaires. When the number of missing
values did not exceed the maximum allowed, we replaced the
missing value by the mean of the remaining scale items.
Otherwise, the scale score was not computed.
Description of the Study Population and Hearing Status
Figure 1 shows the distribution of the National Hearing test
scores. About half of the participants had “insufficient” or
“poor” hearing according to the National Hearing test. Figure 2
illustrates the percentages of participants with good, insuffi-
cient, and poor National Hearing test scores for each age group.
The proportion of people with poor hearing increased with
increasing age. Medians with interquartile ranges (distress,
somatization, loneliness, depression, and anxiety) and means
with standard deviations (age, hearing status, and self-effi-
cacy), stratified by age category, are given in Table 2. Supple-
mentary to the median scores in Table 2, mean scores for the
total sample were 8.2 (SD ⫽7.0) for distress, 6.7 (SD ⫽5.5)
for somatization, 3.3 (SD ⫽3.3) for loneliness, 1.0 (SD ⫽2.2)
for depression, and 2.0 (SD ⫽3.3) for anxiety. Note that for all
psychosocial variables, higher values indicated poorer psycho-
social health. The opposite was true for self-efficacy. On
average, women were significantly younger than men (t⫽10.0,
p⬍0.001), had significantly poorer SRT
scores (t⫽⫺3.04, p⫽
0.002), and had significantly higher distress (t⫽⫺3.55, p⬍
0.001), somatization (t⫽⫺6.68, p⬍0.001), and self-efficacy
scores (t⫽⫺3.80, p⫽0.001). No significant gender differences
for depression, anxiety, and loneliness were found.
Fig. 2. Distribution of good, insufficient, and poor National Hearing test scores for different age categories.
NACHTEGAAL ET AL. / EAR & HEARING, VOL. 30, NO. 3, 302–312 307
Whether participants used headphones or speakers did not
influence the associations between hearing status and psychoso-
cial health; neither interaction effects (t⬍1.55 and p⬎0.122;
Wald ⬍2.63 and p⬎0.105) nor confounding effects were found.
Hearing Status and Psychosocial Health
Table 3 shows the associations between hearing status and
psychosocial health. Multiple linear regression analyses re-
vealed that hearing status was significantly associated with
distress (b⫽0.02, t⫽2.16, p⫽0.031) and somatization (b⫽
0.02, t⫽3.96, p⬍0.001), adjusting for all confounders.
People with higher (poorer) National Hearing test scores
reported higher levels of distress and somatization than people
with better hearing. Note that back transformation was per-
formed for a useful interpretation. After back transformation,
the exponent of the regression coefficient represents a frac-
tional increase or decrease in the dependent variable. For every
dB SNR reduced hearing status, both the distress and somati-
zation score increased by 2%, adjusting for all confounders. No
significant associations between hearing status and self-effi-
cacy were observed. Adjusted and unadjusted logistic regres-
sion models revealed weak but significant associations between
hearing status and depression [odds ratio (OR) ⫽1.05] and
hearing status and loneliness (OR ⫽1.07). For every dB SNR
reduced hearing status, the odds for moderately or severely
elevated depression increased by 1.05 times (Wald ⫽4.61, p⫽
0.03). The odds for severe or very severe loneliness increased
by 7% for every dB SNR reduction in hearing status (Wald ⫽
8.07, p⫽0.004). No significant association between hearing
status and anxiety was found.
The proportion of the population with hearing aids was
23.5%. The above results showed that the risk for psychosocial
health problems increased with poorer hearing status. Subse-
quent analyses were performed for people with an insufficient
or poor hearing status to identify if having hearing aids (yes,
no) significantly influenced psychosocial health. No significant
differences in psychosocial health were found for those with
insufficient or poor hearing status not having a hearing aid
compared with those having hearing aids.
Table 4 presents the regression models for the different age
groups. In the youngest group (18 to 30 yr), decreased hearing
seemed to be significantly associated with increased loneliness
(OR ⫽1.20, Wald ⫽6.57). In the people aged 30 to 39 yr, a
significant negative relationship between hearing status and
distress (b⫽0.04, t⫽2.31) and somatization (b⫽0.04, t⫽
2.54) was observed. Poorer hearing status predicted higher
levels of distress (b⫽0.03, t⫽2.03), self-efficacy (b⫽0.15,
t⫽2.89), depression (OR ⫽1.19, Wald ⫽14.63), and anxiety
(OR ⫽1.18, Wald ⫽4.49) in adults aged 40 to 49 yr.
Somatization (b⫽0.02, t⫽2.20) showed a significant
(adverse) relationship with hearing status in the group aged 50
to 60 yr. In the oldest age group (60 to 70 yr), none of the
(adjusted) associations reached significance.
The present study focused on the association between
psychosocial functioning and hearing status in a large cohort of
adults younger than 70 yr. Significant adverse relationships
between hearing status and psychosocial functioning were
found when adjusting for confounding variables. The associa-
TABLE 2. Descriptive statistics for psychosocial status and covariates stratified by age group
18 –29 yr (n ⫽223) 30–39 yr (n ⫽244) 40 – 49 yr (n ⫽364) 50 –59 yr (n ⫽472) 60 –70 yr (n ⫽208) Overall
Median Range Median Range Median Range Median Range Median Range Median Range
Age§ 24.9 (3.2) 18.2–30 35.7 (2.7) 30 – 40 45.6 (2.9) 40 –50 55.1 (2.9) 50 – 60 62.7 (2.0) 60–70.6 46.3 (12.5) 18.2–70.6
§⫺5.4 (3.4) ⫺10.0 – 4.0 ⫺5.0 (3.3) ⫺10.4– 4.0 ⫺4.9 (3.6) ⫺10.2– 4.0 ⫺4.0 (3.7) ⫺9.6 – 4.0 ⫺3.6 (3.4) ⫺9.6 – 4.0 ⫺4.5 (3.6) ⫺10.4 – 4.0
Distress 6 (3– 6) 0 –31 6.5 (3.5– 6.5) 0 –31 6 (3– 6) 0 –32 7 (4 –5) 0 –32 4 (2–5) 0–29 6 (3– 6) 0 –32
Depression 0 (0 –1) 0 –12 0 (0 –1) 0 –12 0 (0 –1) 0 –12 0 (0 –1) 0 –12 0 (0 – 0) 0 –11 0 (0 –1) 0–12
Anxiety 1 (0 –2) 0 –17 1 (1–2) 0 –16 1(1–1) 0 –27 1 (1–2) 0 –21 1 (1–1) 0 –15 1 (1–1) 0 –27
Somatization 5 (2– 4) 0 –29 5 (2–5) 0 –28 5 (3–5) 0 –28.8 7 (4 –3) 0 –31 5 (3– 4) 0 –23 5.3 (2.3– 4.7) 0–31
Self-efficacy§ 36.3 (3.6) 27.0 – 46.8 36.1 (3.8) 27– 47 35.8 (3.6) 26– 46 35.7 (3.8) 25– 49 35.6 (4.6) 0–23 35.9 (3.9) 19 – 49
Loneliness 2 (2–3) 0 –11 2 (2– 4) 0 –11 2.0 (1.75– 4.0) 0 –11 2 (2– 4) 0 –11 2 (2–3) 0 –11 2 (2– 4) 0 –11
Variables are presented as median (interquartile range) for all variables except for age, hearing status (SRTn), and self-efficacy. For those variables (marked with §), means and standard deviations are presented.
NACHTEGAAL ET AL. / EAR & HEARING, VOL. 30, NO. 3, 302–312308
tion was such that for every dB SNR reduction in hearing
status, the risk for psychosocial dysfunction increased. This
finding is quite alarming, taking into account that a consider-
able number of young and middle-aged people in the popula-
tion worldwide suffer from limited hearing.
When regarding the psychosocial health variables in the
current study, we must note that the group mean scores were
often in the normal range. Nevertheless, every psychosocial
variable showed a wide distribution of scores, with participants
in the normal range and with clinically deviant scores (Table
2). An example is the depression score. Even though the mean
depression score fell under the cutoff score, we found that with
every dB SNR reduction of hearing status, the odds for
developing moderate or severe depression increased by 5%. It
means that for someone with a National Hearing test score of
2 dB SNR, the odds for a moderate or severe depression score
was 1.6 times higher compared with someone with a score of
⫺8 dB SNR. Moderate depression (summed score between 2
and 5) is regarded as a prompt to consider a depressive disorder,
whereas severe depression (summed score ⬎5) should be taken as
a prompt to diagnose a depressive disorder without delay (Terluin
et al. 2006).
The mean somatization and distress scores fell within the
normal range too. Nonetheless, the results demonstrated that
for every dB SNR reduced hearing status, both the distress and
somatization scores increased by 2%, adjusting for all con-
founders. Experiencing a few somatic symptoms in the absence
of a disease is considered normal under stressful circum-
stances. However, the higher the somatization level is the more
likely it is that the symptoms reflect psychological problems,
such as depression (Mayou & Farmer 2002).
Similarly, mild distress states are considered part of normal
life and do not interfere with normal social functioning.
However, elevated levels of distress with symptoms such as
worry, irritability, tension, poor concentration, and insomnia
may force a person to give up and withdraw from major social
roles, especially the occupational role (Terluin et al. 2006). A
large dropout among adults with hearing disability may have
large societal and economical impact (Ruben 2000). We
therefore argue that the societal impact of hearing impairment
in adults younger than 70 yr may even be greater than the
impact in elderly people.
We observed differences in associations between hearing
status and psychosocial health in different age groups. These
dissimilarities could reflect differences in the time of onset of
the hearing impairment or differences in the use of health care.
The differences could also reflect the way hearing impairment
is generally regarded. Whereas among elderly people, de-
creased hearing is usually acknowledged as being part of the
ageing process, young and middle-aged adults often attach a
stigma to hearing impairment. Consequently, a hearing impair-
ment may have greater personal impact in young adults. Our
results demonstrated that loneliness in particular seemed to
occur in that group. Knutson and Lansing (1990) reported
comparable findings and concluded that limited communica-
tion with family and friends may lead to extreme levels of
Self-efficacy increased with decreasing hearing in those
aged 40 to 49 yr, despite large adverse psychosocial effects of
hearing impairment in this age group. Based on our clinical
experience, we argue that this age decade is typical for people
starting to recognize their limitations in hearing activity, in
particular in case of a gradual onset of hearing impairment.
Despite their limitations, people still have to be fully active
both in working and in family life. To function and to
communicate optimally, they need to anticipate in difficult
communication situations (He´tu 1996). Successful anticipation
requires a person to believe in his or her ability to execute
certain behaviors, which is reflected by the self-efficacy score.
So, increased self-efficacy with decreasing hearing at this age
most likely resulted from compensatory behavior to adjust for
limited hearing to communicate optimally. It seems as if this
age group demonstrated a more active anticipation toward
hearing impairment than the other age groups. Interestingly,
Erdman and Demorest (1998) reported similar findings. Their
study involved more than 1000 research participants ranging in
age from 16 to 97 yr. The authors carefully suggested a
nonlinearity in the relationship between age and adjustment to
hearing impairment, with adjustment (as measured with the
Communication Profile for the Hearing Impaired) being poorer
among the youngest and oldest individuals.
Overall, our findings support the results of Tambs (2004),
who also reported a stronger negative effect of hearing impair-
ment on psychosocial wellbeing among younger and middle-
TABLE 3. Association between hearing status, as measured by SRT
screening test, and psychosocial health in the total sample
Distress Somatization Self-efficacy
b95% CI pb95% CI pb95% CI p
Model 1 0.02* 0.00 – 0.03 0.009 0.03* 0.02– 0.04 ⬍0.001 0.05 ⫺0.01– 0.11 0.070
Model 2 0.02* 0.00 – 0.03 0.031 0.02* 0.01– 0.04 ⬍0.001 0.03 ⫺0.03– 0.08 0.315
Loneliness Depression Anxiety
OR 95% CI pOR 95% CI pOR 95% CI p
Model 1 1.07* 1.03–1.12 0.002 1.05* 1.01–1.10 0.013 1.04 0.99 –1.12 0.149
Model 2 1.07* 1.02–1.12 0.004 1.05* 1.00 –1.09 0.032 1.05 0.99 –1.12 0.130
(A) Unstandardized regression coefficients (b), 95% confidence intervals (CI), and pvalues. (B) Odds ratios (OR), 95% CI, and pvalues.
Model 1: univariate.
Model 2: controlling for gender, age, living arrangement, marital status, income, and educational level.
NACHTEGAAL ET AL. / EAR & HEARING, VOL. 30, NO. 3, 302–312 309
aged people compared with older people. However, it must be
noted that the age range in Tambs’ study (20 to 102 yr) was
larger than in the current study (18 to 70 yr), indicating that we
are not able to compare the associations between hearing
impairment and wellbeing in those older than 70 yr.
The sample in the present study was a mixture of people
with and without hearing aids. One may wonder whether
hearing aids had a significant influence on the psychosocial
health status. Subsequent analyses (among people with poor or
insufficient hearing test scores) revealed no differences in the
psychosocial health between the two groups. In other words,
the psychosocial health status was similar for those having
hearing aids compared with those not having hearing aids. This
result does not provide a basis for concluding that hearing aids
are useless. People with hearing aids may have benefited from
their hearing aids significantly, and their status may have been
much worse without. It is known that even with hearing aids,
the majority of persons with severe hearing impairment still do
not hear as those with good hearing.
The relation between hearing status and psychosocial health
could also be influenced by interventions other than hearing
aids (e.g., auditory training). Information on whether respon-
dents received help (other than hearing aids) for their hearing
impairment or not was not available. We assume that some
participants received additional interventions whereas others
did not. We cannot conclude that the data reported in this study
are based on the effects of untreated hearing impairment. The
availability and adequacy of interventions and their influence
on the relationship between hearing status and psychosocial
health need further attention in future research.
Data were collected over the Internet. An often-mentioned
concern is whether Internet data are equivalent to those
collected via regular mail. Several studies in the international
literature dealt with this issue and compared Internet versions
TABLE 4. Association between hearing disability, as measured by the SRT
screening test, and psychosocial health, stratified by age
Distress Somatization Self-efficacy
b95% CI pb95% CI pb95% CI p
18 –29 yr
Model 1 ⫺0.02 ⫺0.05– 0.01 0.221 0.01 ⫺0.02– 0.04 0.535 ⫺0.03 ⫺0.17– 0.11 0.640
Model 2 ⫺0.02 ⫺0.06 – 0.02 0.266 0.00 ⫺0.03– 0.04 0.778 ⫺0.06 ⫺0.20 – 0.09 0.448
30 –39 yr
Model 1 0.04* 0.01– 0.08 0.021 0.06* 0.03–0.09 ⬍0.001 0.04 ⫺0.10 – 0.19 0.591
Model 2 0.04* 0.01– 0.09 0.022 0.04* 0.01–0.07 0.012 ⫺0.01 ⫺0.16– 0.15 0.893
Model 1 0.03* 0.01– 0.06 0.011 0.04* 0.02–0.07 0.001 0.21* 0.11–0.31 ⬍0.001
Model 2 0.03* 0.00 – 0.05 0.043 0.02 ⫺0.00 – 0.05 0.068 0.15* 0.05–0.26 0.004
50 –59 yr
Model 1 0.01 ⫺0.01– 0.03 0.279 0.03* 0.02–0.05 0.003 ⫺0.03 ⫺0.13–0.06 0.510
Model 2 0.01 ⫺0.01– 0.03 0.471 0.02* 0.00 – 0.04 0.028 ⫺0.05 ⫺0.14 – 0.05 0.341
60 –70 yr
Model 1 0.04 ⫺0.00 – 0.07 0.063 0.02 ⫺0.01– 0.06 0.244 0.15 ⫺0.03– 0.34 0.108
Model 2 0.02 ⫺0.01– 0.06 0.203 0.01 ⫺0.02– 0.05 0.528 0.08 ⫺0.11– 0.26 0.397
Loneliness Depression Anxiety
OR 95% CI pOR 95% CI pOR 95% CI p
18 –29 yr
Model 1 1.19* 1.05–1.35 0.005 1.08 0.96 –1.21 0.200 0.98 0.83–1.15 0.770
Model 2 1.20* 1.04 –1.38 0.010 1.08 0.93–1.19 0.427 1.01 0.84–1.21 0.953
Model 1 1.06 0.97–1.19 0.308 1.03 0.93–1.14 0.608 0.99 0.84–1.16 0.884
Model 2 1.08 0.96–1.21 0.207 1.06 0.95–1.18 0.315 0.99 0.83–1.19 0.932
Model 1 1.05 0.97–1.14 0.219 1.15* 1.07–1.24 ⬍0.001 1.12 0.99 –1.26 0.067
Model 2 1.07 0.98 –1.17 0.150 1.18* 1.08 –1.28 ⬍0.001 1.16* 1.01–1.32 0.034
50 –59 yr
Model 1 1.04 0.96 –1.12 0.321 0.97 0.90–1.04 0.370 1.02 0.92–1.13 0.696
Model 2 1.03 0.96 –1.12 0.405 0.96 0.89–1.03 0.248 1.03 0.92–1.14 0.624
60 –70 yr
Model 1 1.17* 1.01–1.35 0.035 1.11 0.98 –1.28 0.108 1.20 0.99 –1.44 0.064
Model 2 1.11 0.94 –1.32 0.211 1.06 0.90–1.24 0.490 1.15 0.92–1.45 0.215
(A) Unstandardized regression coefficients (b), 95% confidence intervals (CI), and pvalues. (B) Odds ratios (OR), 95% CI, and pvalues.
Model 1: univariate.
Model 2: controlling for gender, age, living arrangement, marital status, income, and educational level.
NACHTEGAAL ET AL. / EAR & HEARING, VOL. 30, NO. 3, 302–312310
of health-related questionnaires with paper-and-pencil ver-
sions. Fairly equivalent results for both methods were demon-
strated in the majority of the studies, with fewer missing data
and slightly higher response rates for Internet versions. Overall,
it can be stated that there is satisfactory evidence for the
reliability, validity, and feasibility of online questionnaires
(Hallam et al. 2006; Kongsved et al. 2007; Ritter et al. 2004;
Vallejo et al. 2007).
A possible limitation of speech-in-noise hearing screening
over the Internet is the lack of control over the testing
conditions and the potential variety of equipment used by the
participants. Although participants were requested to do the
test with headphones, a considerable number of participants in
the current study indicated to have used speakers during the
test, which might have influenced the associations found.
However, analyses did not show a confounding or interaction
effect from speaker or headphone use on the association
between hearing status and psychosocial health. Comparable
findings were reported by Culling et al. (2005). They showed
that variations in the type of headphone used during speech-
in-noise hearing screening tests had negligible effects on
speech-in-noise audiometry. Additionally, when loudspeakers
were used in a living room environment, the scores were
extremely similar to those obtained when headphones were
used (Culling et al. 2005). Also, the highly satisfactory test-
retest reliability in the current study confirms the consistency
To avoid excluding groups of respondents and creating bias,
accessibility to the Internet should be guaranteed. We argue
that in our study, accessibility was sufficiently certain because,
in The Netherlands, the proportion of households having access
to the Internet at home is 83%. It is one of the highest
percentages in the world (Dutch Statistics 2007). Moreover, the
percentage of people aged 50 and 65 yr having access to the
Internet is nearly similar to that of the general population (SCP
2007). It may thus be assumed that access to the Internet was
similar for all age groups. In addition, Smits et al. (2006b)
investigated the efficiency and feasibility of the self-screening
hearing test over the Internet. Participants who had accom-
plished the test were asked whether they found the test easy to
perform. Ninety-five percent of the participants responded
positively, reporting that they had no or little difficulty doing
the test. This result further demonstrates the feasibility and
accessibility of the method used.
Nonresponders were significantly younger. Apparently,
maintaining young adults’ interest in participating in scientific
research is difficult. Also, more women than men participated
in the study. An explanation may be that women are inclined to
assign greater importance to effective social communication
than men, report greater problem awareness, and show less
denial associated with hearing impairment (Garstecki & Erler
1999). Men may have greater difficulties with showing their
emotions. Also, women tend to take greater responsibility for
maintaining conversation (Garstecki & Erler 1999). Another
possibility is that women in general are more expressive
regarding health problems and have a lower threshold to seek
help for their problems (Kroenke & Spitzer 1998; Verbrugge
Also, women were significantly younger than men, and the
proportion of participants with a high educational level was
higher compared with the general Dutch population (46%
versus 25%). These facts indicate that our sample is highly
representative for Internet users in general as Internet users are
more likely to have a higher educational level; young women
are more likely than young men to be online; and older men are
more likely than older women to be online (Fallows 2005; SCP
2007). Monthly income and living arrangements of the partic-
ipants of the current study and the general population were
Finally, we conclude that this is the first study in the
literature that relates speech-in-noise screening test scores with
psychosocial health in a large cohort of adults younger than 70
yr. The inability to understand speech in noisy listening
situations is seriously disabling and associated with psychoso-
cial dysfunction. The results inevitably indicate that adverse
effects of hearing impairment in young and middle-aged adults
should not be neglected but seriously addressed both in clinical
practice and in future research.
The authors thank the participants of the National Longitudinal Study on
Hearing. They also acknowledge the assistance of Ton Houffelaar in
managing the database and the additional statistical advice provided by
This study was financially supported by the Heinsius Houbolt Foundation.
Address for correspondence: Janneke Nachtegaal, MSc, Department of
ENT/Audiology, VU University Medical Centre, EMGO Institute, P.O. Box
7057, 1007 MB Amsterdam, The Netherlands. E-mail: j.nachtegaal@
Received March 25, 2008; accepted November 4, 2008.
Bosscher, R. J., & Smit, J. H. (1998). Confirmatory factor analysis of the
General Self-efficacy Scale. Behav Res Ther,36, 339 –343.
Cacciatore, F., Napoli, C., Abete, P., et al. (1999). Quality of life
determinants and hearing function in an elderly population: Ossevatorio
Geriatrico Campano Study Group. Gerontology,45, 323–328.
Carabellese, C., Appollonio, I., Rozzini, R., et al. (1993). Sensory
impairment and quality of life in a community elderly population. JAm
Geriatr Soc,41, 401– 407.
Chia, E. M., Wang, J. J., Rochtchina, E., et al. (2007). Hearing impairment
and health-related quality of life: the Blue Mountains hearing study. Ear
Culling, J. F., Zhoa, F., Stephens, D. (2005). The viability of speech-in-
noise audiometric screening using domestic audio equipment. Int
J Audiol,44, 691–700.
Dalton, D. S., Cruickshanks, K. J., Klein, D. E. K., et al. (2003). The
impact of hearing loss on quality of life in older adults. Gerontologist,
43, 661– 668.
Davis, A. C. (1989). The prevalence of hearing impairment and reported
hearing disability among adults in Great Britain. Int J Epidemiol,18,
De Jong Gierveld, J., & Kamphuis, K. M. (1985). The development of a
Rasch-type loneliness scale. Appl Psychol Measure,9, 289 –299.
Duijvestijn, J. A., Anteunis, L. J., Hendriks, J. J., et al. (1999). Definition
of hearing impairment and its effect on prevalence figures: A survey
among senior citizens. Acta Otolaryngol,119, 420 – 423.
Dutch Statistics (2007). Available at: http://statline.cbs.nl/StatWeb/
3-17&D2⫽0-10&D3⫽a&HDR⫽T. Accessed December 2007.
Erdman, S. A., & Demorest, M. E. (1998). Adjustment to hearing
impairment II: Audiological and demographical correlates. J Speech
Lang Hear Res,41, 123–126.
Eriksson-Mangold, M., & Carlsson, S. G. (1991). Psychological and
somatic distress in relation to perceived hearing disability, hearing
handicap and hearing measurements. J Psychosom Res,35, 729 –749.
NACHTEGAAL ET AL. / EAR & HEARING, VOL. 30, NO. 3, 302–312 311
Fallows, D. (2005). How women and men use the Internet: PEW Internet
& American life project. Available at: http://www.pewinternet.org/pdfs/
Fellinger, J., Holzinger, D., Gerich, J., et al. (2007). Mental distress and
quality of life in the hard of hearing. Acta Psychiatr Scand,115,
Garstecki, D. C., & Erler, S. F. (1999). Older adults performance on the
communication profile for the hearing impaired. J Speech Lang Hear
Gatehouse, S. (1990). Determinants of self-reported disability in older
subjects. Ear Hear, 11 (Suppl), 57S– 65S.
Hallam, R., Ashton, P., Sherbourne, K., et al. (2006). Acquired profound
hearing loss: mental health and other characteristics of a large sample.
Int J Audiol,45, 715–723.
Hannaford, P. C., Simpson, J. A., Bisset, A. F., et al. (2005). The
prevalence of ear, nose and throat problems in the community: Results
from a national cross-sectional postal survey in Scotland. Fam Pract,
Hawthorne, G. (2008). Perceived social isolation in a community: Its
prevalence and correlates of peoples’ lives. Soc Psychiatry Psychiatr
Epidemiol,43, 140 –150.
He´tu, R. (1996). The stigma attached to hearing impairment. Scand Audiol,
Houtgast, T., & Festen, J. M. (2008). On the auditory and cognitive
functions that may explain an individual’s elevation of the speech
reception threshold in noise. Int J Audiol,47, 287–295.
Karlsmose, B., Lauritzen, T., Engberg, M., et al. (2000). A five-year
longitudinal study on hearing in a Danish rural population aged 31–50
years. Br J Audiol,34, 47–55.
King, P. F., Coles, R. R. A., Lutman, M. E., et al. (1992). Assessment of
Hearing Disability: Guidelines for Medicolegal Practice. London:
Knutson, J. F., & Lansing, C. R. (1990). The relationship between
communication problems and psychological difficulties in persons with
profound acquired hearing loss. J Speech Hear Disord,55, 656 – 664.
Kongsved, S. M., Basnov, M., Holm-Christensen, K., et al. (2007).
Response rate and completeness of questionnaires: A randomized study
of Internet versus paper-and-pencil versions. J Med Internet Res,9, e25.
Koster, A., Bosma, H., Kempen, G. I., et al. (2006). Socioeconomic
differences in incident depression in older adults: the role of psychos-
ocial factors, physical health status, and behavioural factors. J Psycho-
som Res,61, 619 – 627.
Kramer, S. E., Kapteyn, T. S., Festen, J. M., et al. (1996). The relationship
between self-reported hearing disability and measures of auditory
disability. Audiology,35, 277–287.
Kramer, S. E., Kapteyn, T. S., Kuik, D. J., et al. (2002). The association of
hearing impairment and chronic diseases with psychosocial health status
in older age. J Aging Health,14, 122–137.
Kroenke, K., & Spitzer, R. L. (1998). Gender differences in the reporting
of physical and somatoform symptoms. Psychosom Med,60, 150 –155.
Lee, P., Smith, J. P., Kington, R. (1999). Relationship of self-rated vision
and hearing to functional status and well-being among seniors 70 years
and older. Am J Ophthalmol,127, 447– 452.
Lipowski, Z. J. (1988). Somatization: the concept and its clinical applica-
tion. Am J Psychiatry,145, 1358 –1368.
Lutman, M. E., Brown, J. E., Coles, R. R. A. (1987). Self-reported
disability and handicap in relation to pure-tone thresholds, age, sex, and
type of hearing loss. Br J Audiol,21, 45–58.
Mathers, C. D., Smith, A., Concha, M. (2003). Global Burden of Hearing
Loss in the Year 2000. Geneva: World Health Organization.
Mayou, R., & Farmer, A. (2002). ABC of psychological medicine:
Functional somatic symptoms and syndromes. BMJ,325, 265–268.
Mulrow, C. D., Aguilar, C., Endicott, J. E., et al. (1990). Association
between hearing impairment and the quality of life in elderly individu-
als. J Am Geriatr Soc,38, 45–50.
Naramura, H., Nakanashi, N., Tatara, K., et al. (1999). Physical and mental
correlates in the elderly in Japan. Audiology,38, 24 –29.
Nilson, M., Soli, S. D., Sullivan, J. A. (1994). Development of the Hearing
in Noise Test for the measurement of speech reception thresholds in
quiet and in noise. J Acoust Soc Am,95, 1085–1099.
Palinkas, L. A., Wingard, D. L., Barret-Conner, E. (1990). Chronic illness
and depressive symptoms in the elderly: a population based study. J Clin
Plomp, R., & Mimpen, A. M. (1979). Improving the reliability of testing
the speech reception threshold for sentences. Audiology,18, 43–52.
Ringdahl, A., & Grimby, A. (2000). Severe profound hearing impairment
and health-related quality of life among post-lingual deafened Swedish
adults. Scand Audiol,29, 266 –275.
Ritter, P., Lorig, K., Laurent, D., et al. (2004). Internet versus mailed
questionnaires: A randomized comparison. J Med Internet Res,6, e29.
Ruben, R. J. (2000). Redefining the survival of the fittest: Communication
disorders in the 21st century. Laryngoscope,110, 241–245.
Sindhusake, D., Mitchell, P., Smith, W., et al. (2001). Validation of
self-reported hearing loss: The Blue Mountains Hearing Study. Int J
Smits, C., & Houtgast, T. (2006). Measurements and calculations on the
simple up-down adaptive procedure for speech-in-noise tests. J Acoust
Soc Am,120, 1608 –1621.
Smits, C., Kapteyn, T. S., Houtgast, T. (2004). Development and validation
of an automatic speech-in-noise screening test by telephone. Int J
Smits, C., Kramer, S. E., & Houtgast, T. (2006a). Speech reception
thresholds in noise and self-reported hearing disability in a general adult
population. Ear Hear,27, 538 –549.
Smits, C., Merkus, P., & Houtgast, T. (2006b). How we do it: the Dutch
functional hearing tests by telephone and Internet. Clin Otolaryngol,31,
436 – 440.
Social and Cultural Planning Office of The Netherlands. Available at:
Accessed December 2007.
Strawbridge, W. J., Wallhagen, M. I., Shema, S. J., et al. (2000). Negative
consequences of hearing impairment in old age: a longitudinal analysis.
Gerontologist,40, 320 –326.
Tambs, K. (2004). Moderate effects of hearing loss on mental health and
subjective well-being. Psychosom Med,66, 776 –782.
Terluin, B., van Marwijk, H. M. J., Ader, H. J., et al. (2006). The
Four-Dimensional Symptom Questionnaire (4DSQ): A validation study
of a multidimensional self-report questionnaire to assess distress,
depression, anxiety and somatisation. BMC Psychiatry,22, 6 –34.
Vallejo, M. A., Jorda´n, C. M., Díaz, M. I., et al. (2007). Psychological
assessment via the internet: A reliability and validity study of online (vs.
paper-and-pencil) versions of the General Health Questionnaire-28
(GHQ-28) and the Symptoms Check-List-90-Revised (SCL-90-R).
J Med Internet Res,9, e2.
Van Tilburg, T. G., & De Leeuw, E. D. (1991). Stability of the scale quality
under various data collections: A mode comparison of the “De Jong-
Gierveld Loneliness Scale.” Int J Public Opin Res,3, 69 – 85.
Van Tilburg, T. G., & De Jong Gierveld, J. (1999). Cesuurbepaling van de
eenzaamheidsschaal [Cutting scores on the De Jong Gierveld Loneliness
Scale]. Tijdschrift voor Gerontologie en Geriatrie,30, 158 –163.
Verbrugge, L. M. (1985). Gender and health: An update on hypotheses and
evidence. J Health Soc Behav,26, 156 –182.
Wallhagen, M. I., Strawbridge, W. J., Kaplan, G. A. (1996). 6-Year impact
of hearing impairment on psychosocial and physiologic functioning.
Nurse Pract,21, 11–14.
Wang, N., Iwasaki, M., Otani, T., et al. (2005). Perceived health as related
to income, socio-economic status, lifestyle, and social support factors in
middle-aged Japanese. J Epidemiol,15, 155–162.
NACHTEGAAL ET AL. / EAR & HEARING, VOL. 30, NO. 3, 302–312312