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The Association Between Hearing Status and Psychosocial Health Before the Age of 70 Years: Results From an Internet-Based National Survey on Hearing

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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 70 yr. 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. Adjusting for confounding variables, significant adverse associations 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. Hearing status is negatively associated with higher distress, 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.
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The Association Between Hearing Status and
Psychosocial Health Before the Age of 70 Years: Results
From an Internet-Based National Survey on Hearing
Janneke Nachtegaal,
1,4
Jan H. Smit,
2,4
Cas Smits,
1,4
Pieter D. Bezemer,
3,4
Johannes H. M. van Beek,
1,4
Joost M. Festen,
1,4
and Sophia E. Kramer
1,4
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
70 yr.
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: b0.02, 95% confidence interval
(CI) 0.00 to 0.03, p0.03; somatization: b0.02, 95% CI 0.01
to 0.04, p0.001]. 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, p0.03). 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, p0.004). 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)
INTRODUCTION
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
Departments of
1
ENT/Audiology,
2
Psychiatry,
3
Clinical Epidemiology and
Biostatistics,
4
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.
302
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
Authors
Population
Hearing status Outcome measures ResultsN Mean age (range) (yr)
Cacciatore et al.
(1999)
1332 74.2 (65–96) Self-report Depression Adverse correlation between hearing status
and depression score
Carabellese et al.
(1993)
1191 (70 –75) Free field
voice test
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;
mental health
Individuals with mild or moderate hearing
loss were more likely to report lower
mental health and social functioning
Eriksson-Mangold and
Carlsson (1991)
48 68.8 (55–74) Audiometry;
self-report
Depression; anxiety;
somatization
Adverse correlation between perceived
hearing disability/handicap and anxiety
and somatization; no correlation with de-
pression
Fellinger et al. (2007) 373 Self-report QOL; distress; anxiety;
somatization;
depression
Higher distress, somatization, and depres-
sion and lower QOL for individuals with
poor hearing
Hallam et al. (2006) 122 54.4; 51.4 (21–80) Self-report Depression; anxiety;
post-traumatic stress
symptoms
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
isolation
Knutson and Lansing
(1990)
27 49.1 (22– 68) Self-report Depression; loneliness
social anxiety;
distress
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;
self-efficacy; social
network size
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
medications
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;
self-esteem;
well-being
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
(2000)
311 66 Audiometry Social isolation;
emotional
reactions
More social isolation and emotional reac-
tions in individuals with poor hearing
Strawbridge et al.
(2000)
2461 65 (50 –102) Self-report Depression; social
functioning
(loneliness)
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
n
)in
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
Procedure
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.
Outcome Measures
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
the SRT
n
. In general, SRT
n
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
telephone version.
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
n
⬍⫺5.5 dB), insufficient (5.5
SRT
n
2.8), and poor (SRT
n
⬎⫺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
0.87.
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
developers.
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.
2006).
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
Netherlands.
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
Participants
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, p0.001)
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.
Potential Confounders
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-
ing effects.
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).
Statistical Analyses
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
logistic regression.
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
were examined.
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.
RESULTS
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 (t10.0,
p0.001), had significantly poorer SRT
n
scores (t⫽⫺3.04, p
0.002), and had significantly higher distress (t⫽⫺3.55, p
0.001), somatization (t⫽⫺6.68, p0.001), and self-efficacy
scores (t⫽⫺3.80, p0.001). 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 (t1.55 and p0.122;
Wald 2.63 and p0.105) 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 (b0.02, t2.16, p0.031) and somatization (b
0.02, t3.96, p0.001), 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, p0.004). 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 (b0.04, t2.31) and somatization (b0.04, t
2.54) was observed. Poorer hearing status predicted higher
levels of distress (b0.03, t2.03), self-efficacy (b0.15,
t2.89), depression (OR 1.19, Wald 14.63), and anxiety
(OR 1.18, Wald 4.49) in adults aged 40 to 49 yr.
Somatization (b0.02, t2.20) 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.
DISCUSSION
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
Variables
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
SRT
n
§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
loneliness.
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
n
screening test, and psychosocial health in the total sample
(N 1511)
Distress Somatization Self-efficacy
b95% CI pb95% CI pb95% CI p
A
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
B
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.
*p0.05.
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
n
screening test, and psychosocial health, stratified by age
group
Distress Somatization Self-efficacy
b95% CI pb95% CI pb95% CI p
A
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
40–49 yr
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
B
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
30 –39
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
40–49 yr
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.
*p0.05.
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
of scores.
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
1985).
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
comparable.
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.
ACKNOWLEDGMENTS
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
Joop Kuik.
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@
vumc.nl.
Received March 25, 2008; accepted November 4, 2008.
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NACHTEGAAL ET AL. / EAR & HEARING, VOL. 30, NO. 3, 302–312312
... The estimated anxiety disorders prevalence ranges from 9.2% to 28.7% with the highest rates in aging adults [8] . Limited research has examined the way that hearing impairment may affect anxiety [9][10][11][12]. ...
Article
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Purpose: With an increasing incidence for hearing impairment, it is necessary to search for the psychological impact on patients. Anxiety prevalence may be raised in people with hearing impairment. This study aimed to evaluate the prevalence of anxiety in hearing loss patients. Methods A case control study included 100 subjects: 50 controls and 50 subjects diagnosed with hearing loss of variable types, degree, and causes. They underwent audiological and Modified Arabic Beck anxiety inventory questionnaire evaluation. First Pure-Tone Audiometry (PTA) was performed in all frequencies to determine the type and level of hearing impairment, then Beck anxiety inventory questionnaire (Modified Arabic form) was done. Results The sample collected showed results of 42% single sided hearing loss while, 58% was bilaterally affected. Anxiety was estimated in 68% of hearing impairment patient with a percentage of 41% male and 59% females. Conclusion Anxiety is a very prevalent problem facing not only subjects with hearing impairment, but also affects a noticeable ratio of apparently normal subjects. So, the psychological assessment and support are needed to be in mind.
... literature reveals the similar results(p=.011) as presenting in current study [22]. ...
Article
Background:Hearing loss (HL)in adults is loss of ability to perceive surrounding environmental sounds. There may be environmental or genetic cause of this disability. Presently expectancy of old adult age isgoing to increase as in the same way hearing problems and its negative impact on health wellbeing standard of living also increased, the beneficial of current study is to be addressed, or give awareness about health consequences to adult population with hearing impairment. Aim: To determine the quality of life in adults with hearing impairment.Place and Duration of Study:Riphah international University, Lahore campus between December 2018 to May 2019. Methodology:A cross sectional survey was conducted on 67 adults with hearing impairment (sample size was calculated on the base of prevalence of hearing loss in the Express Tribute, (March 4, 2014) which was a Pakistani study on hearing impaired population the president of famous organization the developmental diseases and community of auditory handicap MR Afzal estimated the occurrence of auditory deficits in Pakistan region was in between 7 to 8 percent on per 10,000 living birth ,this prevalence was used to calculate sample size by using online calculator).(1), their age range were 18 to 55 (elder adults) and 56 to 97(older adults). Data collection tool which was used in this research was 15D Quality of life questionnaire to find out the influence of hearing loss (HL) on daily living activities in adult’s life. Sampling technique used in this research was convenient sampling. For this purpose, descriptive analysis was done for demographics and chi square was used for inferential analysis by using SPSS20. Endnote was used for references.Results:There are four domains of quality of life (speech, usual activities, mental functioning, and vitality status of participants) which have highly significant relationship value(<0.001) with hearing impairment, in other domains of quality of life p value is less then (<0.05) this means that other domains of quality of life have also significant relationship with hearing impairment except visual or sexual activity of the participants which have no significant association p-value(>0.05)with hearing impairment.Conclusion:Research concluded that domains of quality of life are significantly associated with hearing loss which have negative impact on the QOL(quality of life) except visualor sexual activity, but these two domains may also indirectly have associated or may affect the quality of life individually in adults with hearing impairment
... 5 On the other hand, the number of studies evaluating stress and psychological resilience in hearing-impaired individuals is limited. [6][7][8] Hearing loss is a condition that can be seen in all age groups and causes many handicaps if early intervention is not provided. At least 15% of the Methods: A cross-sectional study. ...
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Aims The aim of the study is to determine the acute stress and psychological resilience level of people with hearing impairment during the COVID-19 pandemic and to investigate the relationship between the grade of hearing impairment, psychological resilience and perceived stress level in this period. Methods A cross-sectional study. A total of 135 hearing-impaired individuals using hearing aids (study group) and 125 healthy individuals (control group) participated. Turkish versions of the Acute Stress Symptoms Scale (ASSS) and Brief Resilience Scale (BRS) were applied to all participants. Turkish version of Amsterdam Inventory for Auditory Disability and Handicap (T-AIADH) was also applied to the study group in addition to other scales. The presence of any difference between the groups in terms of ASSS and BRS scores was investigated. Results There was a statistically significant difference between the control group and the study group in terms of ASSS results (Z=-4.4, p=0.00). No statistically significant difference was found between the control group and the study group in terms of BRS scores (Z=-0.248, p=0.804). Furthermore, T-AIADH scale was observed not to correlate either with ASSS or BRS (p>0.05). In the study group, change in income level after the pandemic, age, and sex variables were determined as a significant predictor of ASSS. Conclusion Identifying risks and protective factors for hearing-impaired individuals at the early stage of the epidemic is considered to be of critical importance to predict the psychological impact of both the epidemic and the response to the COVID-19 health crisis, and to reduce stress.
... In many (not all) of these indirect pathways proposed, hearing aids have been shown to be beneficial. Specifically, hearing aids have been shown to improve speech perception and communication function (Ferguson et al., 2017;Scarinci et al., 2012;Schulz et al., 2017;Wallhagen et al., 2004), reduced psychosocial implications of hearing loss (Cox et al., 2014;Johnson et al., 2016;Sprinzl & Riechelmann, 2010), improved health-and hearing-related quality of life (Mick et al., 2014;Mick & Pichora-Fuller, 2016;Nachtegaal et al., 2009;Scarinci et al., 2012;Schulz et al., 2017), and may reduce cognitive load and effortful listening during daily activities (Dawes et al., 2015;Maharani et al., 2018). Our scientific premise, for which this study is based, is that, if the hearing loss and falls association are mediated by these indirect auditory pathways, then differences may exist between hearing aid users and nonusers. ...
Article
Purpose Falls are considered a significant public health issue, and hearing loss has been shown to be an independent risk factor for falls. The primary objective of this study was to determine if hearing aid use modified (reduced) the association. We hypothesized that routine hearing aid use would reduce the impact of hearing loss on the odds of falling. If hearing aid users have reduced odds of falling, then that would have an important impact on falls prevention health care. Method Data from 8,091 individuals 40 years of age and older who completed National Health and Nutrition Examination Survey (NHANES) cycles 1999–2004 were used. NHANES comprises a series of cross-sectional studies, each of which is representative of the total civilian noninstitutionalized population of children and adults in the United States, enabling unbiased national estimates of health that can be independently reproduced. Self-reported hearing, hearing aid status, falls history, and comorbidities were extracted and analyzed using regression modeling. Results The 8,091 individuals were grouped based on a self-reported history of falls in the last year. Self-reported hearing loss was significantly associated with odds of falling. Categorizing individuals based on routine hearing aid use was included as an interaction term in the fully adjusted models and was not significant, suggesting no difference in falls based on hearing aid status. Conclusions The unique results of the current study show that when examining self-reported hearing in a nationally representative sample, hearing aid use does not appear to mitigate or modify the association between self-reported hearing and falls. Future research designs are highlighted to address limitations identified using NHANES data for this research and focus on the use of experimental designs to further understand the association between hearing loss and falls, including whether hearing loss may be a modifiable risk factor for falls. Supplemental Material https://doi.org/10.23641/asha.14642784
Article
Objective In many countries the retirement age is rising. Consequently, age-related hearing loss is an increasing occupational health problem. This study examined the association between hearing loss and sustainable employability of teachers. Design For this cross-sectional study a survey and an online hearing screening test were used. Sustainable employability was measured with the Capability Set for Work Questionnaire (CSWQ), examining seven work values. CSWQ-scores of teachers with poor, insufficient, and good hearing were investigated with ordinal regression analyses. Work values and discrepancies between the importance and achievement of the values were examined by chi-square tests. Study sample Dutch teachers (N = 737) of whom 146 (20%) had insufficient and 86 (12%) poor hearing. Results Teachers with insufficient (OR = 0.64; 95% CI 0.46–0.89) and poor (OR = 0.55; 95% CI 0.36–0.83) hearing had lower CSWQ-scores compared with good hearing teachers. Adjustment for covariates, in particular for self-rated health, attenuated the associations. Compared with good hearing teachers, teachers with poor hearing reported more discrepancies in using their knowledge and skills and setting their own goals at work. Conclusions Hearing loss was negatively associated with sustainable employability of teachers. This emphasises the importance of assessing the hearing status of teachers.
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Background: eHealth and social media could be of particular benefit to adults with hearing impairment, but it is unknown whether their use of smart devices, apps, and social media is similar to that of the general population. Objective: Our aim is to study whether adults with normal hearing and those with impaired hearing differ in their weekly use of smart devices, apps, and social media; reasons for using social media; and benefits from using social media. Methods: We used data from a Dutch cohort, the National Longitudinal Study on Hearing. Data were collected from September 2016 to April 2020 using a web-based questionnaire and speech-in-noise test. The results from this test were used to categorize normal hearing and hearing impairment. Outcomes were compared using (multiple) logistic regression models. Results: Adults with impaired hearing (n=384) did not differ from normal hearing adults (n=341) in their use of a smartphone or tablet. They were less likely to make use of social media apps on a smartphone, tablet, or smartwatch (age-adjusted odds ratio [OR] 0.67, 95% CI 0.48-0.92; P=.02). Use of social media on all devices and use of other apps did not differ. Adults with hearing impairment were more likely to agree with using social media to stay in touch with family members (OR 1.54, 95% CI 1.16-2.07; P=.003) and friends (age-adjusted OR 1.35, 95% CI 1.01-1.81; P=.046). Furthermore, they were more likely to agree with using social media to perform their work (age-adjusted OR 1.51, 95% CI 1.04-2.18; P=.03). There were no differences in the experienced benefits from social media. Conclusions: The potential for eHealth is confirmed because adults with hearing impairment are not less likely to use smart devices than their normal hearing peers. Adults with hearing impairment are less likely to use social media apps on a smart device but not less likely to use social media on all types of internet-connected devices. This warrants further research on the types of social media platforms that adults with hearing impairment use and on the type of device on which they prefer to use social media. Given that participants with hearing impairment are more likely than their normal hearing peers to use social media to perform their work, use of social media may be seen as an opportunity to enhance vocational rehabilitation services for persons with hearing impairment.
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El envejecimiento progresivo de la población mundial es una preocupación reconocida por la mayoría de las propuestas de políticas públicas en diversas áreas, incluida salud. La persona mayor pertenece a un grupo social vulnerable, que requiere ser considerado en las intervenciones y políticas de salud pública. Existe una considerable pérdida de las capacidades sensoriales y motrices que suponen una disminución de la autonomía, la que si se asocia a la realidad de las personas mayores con menos ingresos, dificulta un acceso oportuno a prestaciones de salud para poder enfrentar la discapacidad de manera apropiada. Las consecuencias de la pérdida de la capacidad auditiva en la persona mayor se manifiestan en problemas de la comprensión del habla, deterioro cognitivo y trastornos de la salud mental como ansiedad y depresión. Lamentablemente, las intervenciones para aumentar la adherencia de los usuarios al uso de audífonos no han mostrado muchos resultados favorables. Un correcto diagnóstico permite tener una orientación y rehabilitación adecuada a través de la generación de programas y estrategias enfocadas en la integración social, permitiendo que la calidad de vida se mantenga o mejore no solo en las personas con hipoacusia. Implementar un abordaje que busque tener un impacto positivo en la adherencia al uso de audífonos debe incluir y desarrollar programas de rehabilitación auditiva que consideren aspectos de contexto como vivienda, red de apoyo e integración social, entre otros.
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Objectives Social isolation and loneliness are interrelated but independent constructs that threaten healthy aging and well-being and are thought to be associated with hearing loss. Our aim was to review the empirical studies that have examined the association between hearing loss and social isolation and/or loneliness to highlight future research needs. Design Scoping review. Study sample Three electronic databases were searched combining key terms of “hearing loss”, “hearing impairment” and “deaf*” with “social isolation” or “loneliness”, yielding an initial result of 939 articles. After removing duplicate articles, abstract screening and full-text review, 57 original articles met our inclusion criteria. Results Studies were diverse in terms of methodology with the most common type of study being studies that have explored the relationship between hearing loss and social isolation/loneliness from large population-based datasets. Only eight studies were intervention studies and of these, only one specifically explored the outcomes of hearing aids (HAs) on social isolation/loneliness. Conclusions Further research is warranted to examine the influence that hearing interventions, in particular HAs, have on social isolation and/or loneliness, with a specific need to include people who identify as being socially isolated and/or lonely at baseline.
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BACKGROUND: The Four-Dimensional Symptom Questionnaire (4DSQ) is a self-report questionnaire that has been developed in primary care to distinguish non-specific general distress from depression, anxiety and somatization. The purpose of this paper is to evaluate its criterion and construct validity. METHODS: Data from 10 different primary care studies have been used. Criterion validity was assessed by comparing the 4DSQ scores with clinical diagnoses, the GPs' diagnosis of any psychosocial problem for Distress, standardised psychiatric diagnoses for Depression and Anxiety, and GPs' suspicion of somatization for Somatization. ROC analyses and logistic regression analyses were used to examine the associations. Construct validity was evaluated by investigating the inter-correlations between the scales, the factorial structure, the associations with other symptom questionnaires, and the associations with stress, personality and social functioning. The factorial structure of the 4DSQ was assessed through confirmatory factor analysis (CFA). The associations with other questionnaires were assessed with Pearson correlations and regression analyses. RESULTS: Regarding criterion validity, the Distress scale was associated with any psychosocial diagnosis (area under the ROC curve [AUC] 0.79), the Depression scale was associated with major depression (AUC = 0.83), the Anxiety scale was associated with anxiety disorder (AUC = 0.66), and the Somatization scale was associated with the GPs' suspicion of somatization (AUC = 0.65). Regarding the construct validity, the 4DSQ scales appeared to have considerable inter-correlations (r = 0.35-0.71). However, 30-40% of the variance of each scale was unique for that scale. CFA confirmed the 4-factor structure with a comparative fit index (CFI) of 0.92. The 4DSQ scales correlated with most other questionnaires measuring corresponding constructs. However, the 4DSQ Distress scale appeared to correlate with some other depression scales more than the 4DSQ Depression scale. Measures of stress (i.e. life events, psychosocial problems, and work stress) were mainly associated with Distress, while Distress, in turn, was mainly associated with psychosocial dysfunctioning, including sick leave. CONCLUSION: The 4DSQ seems to be a valid self-report questionnaire to measure distress, depression, anxiety and somatization in primary care patients. The 4DSQ Distress scale appears to measure the most general, most common, expression of psychological problems
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Data collection procedures can influence respondents' self-disclosure, accuracy and motivation to complete the interview. In comparing research results across different studies, it is important to use robust measuring instruments. The ‘De Jong-Gierveld Loneliness Scale’ was developed to measure loneliness among different populations and in studies with different designs. Data on this loneliness scale were re-analyzed to investigate the robustness of the scale. The data were from six Dutch surveys. Different interview modes were used for data collection: three surveys with self-administered paper questionnaires, two surveys with face-to-face interviews, and one telephone survey. In order to compare the properties of the loneliness scale, a relatively homogeneous category of respondents was selected: single women between the ages of 25 and 65. An examination of the scale with regard to five aspects of robustness showed in very few cases that it was affected. No evidence was found for the assumption that the use of a self-administered questionnaire would lead to high item non-response, any higher than using other data collection procedures. It was also assumed that in self-administered questionnaires or telephone interviews, a better inter-item homogeneity and a better person scalability would be found in studies with face-to-face interviews. The results sustained this hypothesis. Further, it was believed that the absence of an interviewer would result in greater self-disclosure and therefore in higher scale means. We found on evidence to support this. In general the results showed that the loneliness scale met the psychometric requirements of items non-response, scale homogenity and person scalability. After testing the robustness of the scale, we conclude that it is questionable on two aspects: the inter-item homogeneity and the person scalability.
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The authors investigate the impact of hearing loss on quality of life in a large population of older adults. Data are from the 5-year follow-up Epidemiology of Hearing Loss Study, a population-based longitudinal study of age-related hearing impairment conducted in Beaver Dam, WI. Participants (N = 2,688) were 53-97 years old (mean = 69 years) and 42% were male. Difficulties with communication were assessed by using the Hearing Handicap for the Elderly-Screening version (HHIE-S), with additional questions regarding communication difficulties in specific situations. Health-related quality of life was assessed by using measures of activities of daily living (ADLs), instrumental ADLs (IADLs) and the Short Form 36 Health Survey (SF-36). Hearing loss measured by audiometry was categorized on the basis of the pure-tone average of hearing thresholds at 0.5, 1, 2, and 4 kHz. Of participants, 28% had a mild hearing loss and 24% had a moderate to severe hearing loss. Severity of hearing loss was significantly associated with having a hearing handicap and with self-reported communication difficulties. Individuals with moderate to severe hearing loss were more likely than individuals without hearing loss to have impaired ADLs and IADLs. Severity of hearing loss was significantly associated with decreased function in both the Mental Component Summary score and the Physical Component Summary score of the SF-36 as well as with six of the eight individual domain scores. Severity of hearing loss is associated with reduced quality of life in older adults.
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This paper describes an attempt to construct a measuring instrument for loneliness that meets the cri teria of a Rasch scale. Rasch (1960, 1966) proposed a latent trait model for the unidimensional scaling of di chotomous items that does not suffer from the inade quacies of classical approaches. The resulting Rasch scale of this study, which is based on data from 1,201 employed, disabled, and jobless adults, consists of five positive and six negative items. The positive items assess feelings of belongingness, whereas the negative items apply to three separate aspects of miss ing relationships. The techniques for testing the as sumptions underlying the Rasch model are compared with their counterparts from classical test theory, and the implications for the methodology of scale con struction are discussed.
Objectives: To determine the economic effect on the US economy of the cost of caring for people with communication disorders as well as the cost of lost or degraded employment opportunities for people with such disorders, including disorders of hearing, voice, speech, and language. Study Design: Survey of available historical and contemporary governmental and scholarly data concerning work force distribution and the epidemiology of disorders of hearing, voice, speech, and language. Method: Analysis of epidemiological and economic data for industrialized countries, North America, and the United States. Results: Communication disorders are estimated to have a prevalence of 5% to 10%. People with communication disorders may be more economically disadvantaged than those with less severe disabilities. The data suggest that people with severe speech disabilities are more often found to be unemployed or in a lower economic class than people with hearing loss or other disabilities. Communication disorders may cost the United States from $154 billion to $186 billion per year, which is equal to 2.5% to 3% of the Gross National Product. Conclusions: Communication disorders reduce the economic output of the United States, whose economy has become dependent on communication-based employment. This trend will increase during the next century. The economic cost and the prevalence rates of communication disorders in the United States indicate that they will be a major public health challenge for the 21st century.
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Concern about symptoms is a major reason for patients to seek medical help. Many of the somatic symptoms that they present with—such as pain, weakness, and fatigue—remain unexplained by identifiable disease even after extensive medical assessment. Several general terms have been used to describe this problem—somatisation, somatoform, abnormal illness behaviour, medically unexplained symptoms, and functional symptoms. We will use the term functional symptoms, which does not assume psychogenesis but only a disturbance in bodily functioning. Some common functional symptoms and syndromes Muscle and joint pain (fibromyalgia)Low back painTension headacheAtypical facial painChronic fatigue (myalgic encephalomyelitis)Non-cardiac chest painPalpitationNon-ulcer dyspepsiaIrritable bowelDizzinessInsomnia Classification of functional syndromes Most functional symptoms are transient, but a sizeable minority become persistent. Persistent symptoms are often multiple and disabling and may be described as functional syndromes. Although different medical and psychiatric classifications of functional syndromes exist, these are simply alternative ways of describing the same conditions. René Descartes, who formulated the philosophical principle of separation of brain and mind. This has led to continuing dualism—separation of body and mind—in Western medicine and difficulty in accepting the interaction of physical and psychological factors in aetiology Medical syndromes(such as fibromyalgia and chronic fatigue, chronic pain, and irritable bowel syndromes) highlight patterns of somatic symptoms, often in relation to particular bodily systems. Although they are useful in everyday medical practice, recent studies show there is substantial overlap between them. Psychiatric syndromes(such as anxiety, depression, and somatoform disorders) highlight psychological processes and the number of somatic symptoms irrespective of the bodily system to which they refer. Depression and anxiety often present with somatic symptoms that may resolve with effective treatment of these disorders. In other cases the appropriate psychiatric diagnostic category is a somatoform disorder. The existence of parallel classificatory systems is confusing. Both have merits, and both are imperfect. For …
Article
Speech-in-noise audiometry has potential application as a low-cost, self-screening test for sensorineural hearing loss. To realize this potential, the influence of variations in audio equipment and listening environment need assessment. The present study assessed: 1) the frequency response and distortion produced by a wide range of commercially available audio equipment; 2) the effects of such variations upon test results with normally hearing subjects using a simple, open-set, word-identification test; 3) the effect of distortion on the speech reception threshold using digitally applied distortion; and 4) the reliability of the test in listening environments with different levels of reverberation. In addition, preliminary tests were conducted with elderly listeners. The results indicate that variations in equipment have negligible effects on speech-in-noise audiometry. The only factor that substantially elevated normally hearing listeners’ thresholds was high levels of room reverberation when using loudspeaker presentation. Variations in equipment and environment thus present no significant obstacle to the development of a self-administered audiometric screening test based on speech in noise. Sumario La logoaudiometría en ruido tiene una aplicación potencial como prueba de auto-evaluación a bajo costo para pérdidas auditivas sensorineurales. Para desarrollar este potencial se necesita evaluar la influencia de las variaciones en el equipo de audio y en el ambiente de escucha. El presente estudio evaluó: 1) la respuesta frecuencial y la distorsión producida por una amplia gama de equipos de audio disponibles comercialmente; 2) los efectos de tales variaciones sobre los resultados de las evaluaciones con sujetos normo-oyentes usando una prueba de identificación de palabras de contexto abierto; 3) el efecto de distorsión sobre el umbral de recepción del lenguaje utilizando distorsión digitalmente aplicada; 4) la confiabilidad de la prueba en ambientes para escuchar con diferentes niveles de reverberación. Los resultados indican que las variaciones en el equipo generan efectos despreciables en la logoaudiometría en ruido. El único factor que elevó sustancialmente los umbrales en sujetos normo-oyentes fueron los altos niveles de reverberación de la cabina cuando la presentación se hizo a través de altoparlantes. Las variaciones en el equipo o en el ambiente, por lo tanto, no constituyeron un obstáculo significativo en el desarrollo de una prueba auto-administrada de tamizaje auditivo basada en lenguaje en ruido.