Social Support Predicts Hearing Aid Satisfaction Gurjit Singh,1,2,3 Sin-Tung Lau,3 and M. Kathleen Pichora-Fuller3,4

Objectives: The goals of the current research were to determine: (1) whether there is a relationship between perceived social support and hearing aid satisfaction, and (2) how well perceived social support predicts hearing aid satisfaction relative to other correlates previously identified in the literature.

conditions (for review, see Broadhead et al. 1983; Cohen & Wills 1985). For example, in one particularly striking study, it was found that the risk of mortality associated with social isolation is as strong as that of other clinical risk factors, including cigarette smoking (House et al. 1988) and high blood pressure (Pantell et al. 2013). Typically, the availability of social support promotes positive health outcomes through the use of effective coping strategies and the attenuation of negative interpretations of adverse events. The concept of social support has been defined in a variety of ways, and it is important to distinguish between social support and related but distinct concepts such as social network. Social support refers to the perceived quality, rather than the quantity, of relationships providing emotional or affective support, instrumental support, and/or informational support (Broadhead et al. 1988; Cohen 2004). Affective support involves the expression of emotions, such as empathy, whereas instrumental support refers to support that is provided in the form of material goods (e.g., financial aid). Examples of informational support include advice that may be provided to help an individual cope with a problem (Cohen 2004). Although social support has been investigated in other areas of health research, little is known about the relationship between social support and hearing aid outcomes. Currently, however, there is increasing recognition of the importance of social factors in audiologic rehabilitation. The objective of the present study is to expand upon previous research on hearing aid outcomes by investigating the relationship between perceived social support and satisfaction with hearing aids.

Design: In study 1, 173 adult ( x age = 68.9 years; SD = 13.4) users of hearing aids completed a survey assessing attitudes toward health, hearing, and hearing aids, as well as a questionnaire assessing BigFive personality factors (Openness to Experience, Conscientiousness, Extraversion, Agreeableness, and Neuroticism) either using paper and pencil or the Internet. In a follow-up study designed to replicate and extend the results from study 1, 161 adult ( x age = 32.8 years; SD = 13.3) users of hearing aids completed a similar survey on the Internet. In study 2, participants also completed a measure of hearing aid benefit and reported the style of their hearing aid. Results: In studies 1 and 2, perceived social support was significantly correlated with hearing aid satisfaction (respectively, r = 0.34, r = 0.51, ps < 0.001). The results of a regression analysis revealed that in study 1, 22% of the variance in hearing aid satisfaction scores was predicted by perceived social support, satisfaction with one’s hearing health care provider, duration of daily hearing aid use, and openness. In study 2, 43% of the variance in hearing aid satisfaction was predicted by perceived social support, hearing aid benefit, neuroticism, and hearing aid style. Overall, perceived social support was the best predictor of hearing aid satisfaction in both studies. After controlling for response style (i.e., acquiescence or the tendency to respond positively), the correlation between perceived social support and hearing aid satisfaction remained the same in study 1 (r = 0.34, p < 0.001) and was lower in study 2 (r = 0.39, p < 0.001), although the change in correlation was not significant. Conclusions: The results from study 1 provide evidence to suggest that perceived social support is a significant predictor of satisfaction with hearing aids, a finding that was replicated in a different sample of participants investigated in study 2. A significant relationship between perceived social support and hearing aid satisfaction was observed in both studies, even though the composition of the two samples differed in terms of age, relationship status, income, proportion of individuals with unilateral versus bilateral hearing impairment, and lifetime experience with hearing aids. The results from both studies 1 and 2 provide no support for the claim that participant response style accounts for the relationship between hearing aid satisfaction and perceived social support.

Satisfaction With Hearing Aids Among the hearing aid outcomes commonly investigated, satisfaction is an important outcome variable that has garnered the attention of researchers and clinicians. Understanding perceived satisfaction is important for several reasons. First, as noted by Wong et al. (2009), because hearing aids are consumer products, it is important to examine the factors that influence consumer satisfaction with them. Second, a low level of satisfaction with hearing aids is often cited as one reason why a large proportion of individuals who have hearing aids do not use them (Kochkin 2000). Third, given the high prevalence of hearing loss (World Health Organization 2011) and the fact that hearing aids are a commonly prescribed form of treatment, there is value in identifying factors associated with hearing aid satisfaction so that the long-term outcomes of hearing rehabilitation interventions can be optimized. Research concerning the factors influencing consumer satisfaction with hearing aids has been conducted for more than two decades in the MarkeTrak surveys (e.g., Kochkin 1992, 2000, 2005, 2007, 2010) and summarized in two reviews, one published over a decade ago (Wong et al. 2003) and another published more recently (Knudsen et al. 2010). The MarkeTrak surveys have focused on the relationship between satisfaction with hearing aids and audiologic (e.g., degree of hearing loss, hearing disability), hearing aid

Key words: Assistive devices, Audiologic rehabilitation, Hearing aid outcomes, Hearing aids, Perceived social support, Satisfaction. (Ear & Hearing 2015;36;664–676)

INTRODUCTION Over the past 30 years, research in health psychology has examined the role of social support on health outcomes, and the availability of social support has been found to be a powerful factor influencing health outcomes across a number of health Phonak Canada Ltd, Mississauga, Ontario, Canada; 2Department of SpeechLanguage Pathology, University of Toronto, Toronto, Ontario, Canada; 3 Department of Research, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada; and 4Department of Psychology, University of Toronto Mississauga, Mississauga, Ontario, Canada. 1

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(e.g., performance in different listening environments, overall benefit, age of hearing aids, type of technology), personal (e.g., quality of life), and demographic (e.g., employment status) factors. In general, these surveys have reported that factors related to the hearing aid (e.g., sound clarity, perceived value, perceived benefit, reliability of the device, and comfort with loud sounds) are the best predictors of overall satisfaction. In a review conducted over a decade ago, Wong et al. (2003) summarized the findings of 45 articles investigating the association between satisfaction with hearing aids and audiologic (e.g., self-reported disability or handicap, objective benefit), demographic (e.g., age, socioeconomic status), personal (e.g., attitude, personality, locus of control), and general health factors. The authors reported that, across multiple studies, several factors have been identified as significant correlates of hearing aid satisfaction. It is noteworthy that most of these factors are tied to the person’s experience with the technology, namely duration of experience with hearing aids, higher rates of daily usage, style of hearing aid (e.g., in-the-ear, behind-the-ear), the number of different listening environments in which hearing aids improve listening abilities, subjective benefit, and sound quality (e.g., naturalness). Two factors associated with satisfaction with hearing aids that are more psychological in nature are prefitting attitudes toward hearing aids (e.g., expected utility), and personality. In contrast, investigations of the association between satisfaction with hearing aids and other variables (expectations about hearing aids, self-reported disability, degree of hearing loss, and postfitting counseling) have either produced conflicting results or more research is required to provide more conclusive evidence of whether or not a relationship exists. For example, of the 11 studies examined by Wong et al. (2003) that investigated the relationship between satisfaction and selfreported disability, six studies reported finding no significant relationship, two studies identified a significant relationship, and three studies yielded inconclusive findings. The ability to compare the results of these studies and other research conducted on hearing aid satisfaction is further complicated by the fact that different study instruments have been used to measure the same concept (Wong et al. 2003). A more recent and systematic review of factors that influence hearing aid uptake, hearing aid use, and hearing aid satisfaction was conducted by Knudsen et al. (2010). Overall, they found that there is evidence to support a positive correlation between hearing aid satisfaction and self-reported hearing problems, lifetime hearing aid experience, dexterity, and satisfaction with one’s hearing aid professional. Mixed evidence was observed to support an association between hearing aid satisfaction and several factors including prefitting motivations to seek help, prefitting expectations about hearing aids, perceived benefit, personality, hearing sensitivity as measured by the audiogram, and participation in counseling programs. Finally, little to no evidence was observed supporting an association between hearing aid satisfaction and prefitting attitude to one’s hearing loss, age, sex, socioeconomic status, and living arrangements. In summary, the repeated MarkeTrak surveys over the last two decades, a comprehensive review over a decade ago by Wong and colleagues, and a more recent review by Knudsen and colleagues have continued to find that satisfaction with hearing aids is related to factors associated with the technology and also to the experience of the person in using the technology. A relationship between hearing aid satisfaction and personality

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has also been found but has been studied less frequently. Notably, social factors have not been sufficiently investigated.

Psychosocial Factors Related to Hearing Aid Satisfaction The World Health Organization’s International Classification of Functioning, Disability, and Health (WHO-ICF; World Health Organization 2002) framework recommends that disability be considered within the context of a person’s environment and that an individual’s ability to function in daily life be determined by multiple interacting factors (e.g., psychosocial factors). However, a recent review of the WHO-ICF core sets for hearing loss noted that the social context of people who are hard-of-hearing is underrepresented in rehabilitative audiology (Danermark et al. 2013; Granberg et al. 2014a, 2014b, 2014c; see also ICF Research Branch 2013). Within the literature investigating hearing aid satisfaction, few studies have explored how psychosocial variables relate to perceived satisfaction, and to our knowledge, there have been no studies on the relationship between hearing aid satisfaction and social support. Thus, research investigating the role of social support in audiologic rehabilitation more generally, and hearing aid satisfaction specifically, addresses an existing gap in the application of the WHO-ICF framework to hearing loss. Some studies have examined the effects of hearing loss on individuals and their significant others (e.g., Hétu et al. 1987, 1993; Stephens et al. 1995; Stephens 1996; Heine et al. 2002; Kramer et al. 2002; Danermark & Gellerstedt 2004; Stark & Hickson 2004; Wallhagen et al. 2004; Scarinci et al. 2008, 2009; Carlsson et al. 2011). Other studies have investigated the psychosocial benefits associated with audiologic rehabilitation (e.g., Erber 1996, 2002; Day & Jutai 1996; Crandell 1998; Palmer et al. 1999; Noble 2002; Joore et al. 2003; Saunders & Jutai 2004; Stark & Hickson 2004; Preminger 2007). Critically, and as noted earlier, research identifying psychosocial influences on hearing aid satisfaction is lacking and has largely been limited to studies on the effects of personality and attitude. The relationship between personality factors and hearing aid satisfaction scores has been found to be significant but weak (Meister et al. 2012).

The Role of Social Support in Hearing Health Care Research investigating the effects of social support for individuals with hearing impairment has typically been conducted using either qualitative research methodologies or correlational analyses of survey responses. Erber (1996) suggested that successful use of hearing aids is likely dependent on support from communication partners. Research interviews have found that significant others can act as a source of motivation and support for those using hearing aids (Carson 2005; Lockey et al. 2010). Interviews conducted with significant others similarly suggest that this group can be aware of their role in the rehabilitation process. For example, significant others report that they can encourage the person who is hard-of-hearing to pursue and adhere to treatment, act as a facilitator for communication (e.g., reiterating the topic of conversation, interpretation services), and provide information and instruction on the proper use and operation of hearing aids (Mahoney et al. 1996; van den Brink et al. 1996; Manchaiah et al. 2013). Importantly, there is also evidence suggesting that

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the negative attitudes of significant others toward hearing aids can influence the attitudes and behaviors of persons who are hard-of-hearing by influencing them to either delay help-­seeking or reject treatment options (Brooks 1989; Kochkin 2007). Research using survey methodologies has largely supported and complemented the findings observed in qualitative research. In a sample of 1419 persons, Duijvestijn et al. (2003) found that help-seeking was more likely to take place when significant others exerted social pressure. In a more recent study, Meyer et al. (2014) examined the contributions of audiologic and nonaudiologic factors on help-seeking behaviors for 307 hearing-impaired listeners and found that help-seeking was best predicted by attitudinal beliefs, such as perceived benefit from hearing aids and external cues to action, such as support from significant others. Significant others can assist clinicians to understand the communication difficulties of hearing-impaired persons, but the accuracy of their reports might possibly be lower in cases where incentives exist to exaggerate the degree of disability (Newman & Weinstein 1986; Chmiel & Jerger 1993; Lormore & Stephens 1994). Garstecki and Erler (1998) compared nonmatched groups of older adults with hearing loss who either accepted or rejected advice from a hearing health care practitioner to obtain and use amplification; they found that the availability of social support was one of the several factors that were positively associated with hearing aid use (see also van den Brink et al. 1996). A recent study by Hickson et al. (2014) identified five factors that differentiate successful users of hearing aids from unsuccessful users of hearing aids. Not only were successful owners of hearing aids more likely to report that they received greater social support from significant others than unsuccessful users of hearing aids but the reported availability of social support was the best predictor of group membership. Frankel and Turner (1983) examined data from 420 adults with hearing loss who completed questionnaires assessing communication handicap, psychological distress (e.g., depression, anxiety, paranoia), and measures assessing perceived social support; they found that social support was a strong predictor of adjustment to the psychological distress associated with hearing loss. A newer possibility is that social support can potentially be provided on the Internet. Cummings et al. (2002) found that the frequency of participation in an online self-help group for hearing loss was predicted by a lack of real-world social support and was positively correlated with subjective benefit (e.g., positive ratings of perceived helpfulness). Curiously, there is evidence to suggest that hearing aid seekers tend to use coping mechanisms that rely on social support less frequently than peers with normal or near-normal hearing (Cox et al. 2005). Only a few studies have evaluated the efficacy of including significant others in aural rehabilitation classes for individuals with hearing loss (e.g., Hétu & Getty 1991; Hickson et al. 1996). Even fewer studies have been designed to systematically test the benefits arising from social support. A notable exception is Preminger (2003) who compared perceived hearing handicap for persons with hearing loss who attended rehabilitation sessions either with or without a significant other. Importantly, they found that attendance with a significant other resulted in larger reductions in hearing handicap scores than if the classes were attended alone. In summary, the research on social support in audiologic rehabilitation suggests that significant others can encourage help-seeking, advocate for (or against) the adoption of hearing aids, provide instruction on the proper care and operation of

hearing aids, act as a source of motivation to reinforce the continued use of hearing aids, facilitate communication by helping to relay information during conversations or reiterating the topic of conversation, provide social support on the Internet, and reduce hearing disability after participation in rehabilitation classes. The availability of social support is also associated with both greater adherence to treatment recommendations for amplification and less hearing-related psychological distress. For these reasons, it is possible that the availability of social support may be related to how much satisfaction a person experiences with their hearing aids.

The Current Research There are two main goals for the current research. First, we set out to determine whether there is a relationship between social support and satisfaction with amplification. A higher level of perceived social support is hypothesized to be associated with greater satisfaction with hearing aids. Second, we conducted a regression analysis to estimate the relative association between social support and hearing aid satisfaction compared to associations with other variables that have previously been found to be significant predictors of hearing aid satisfaction. Understanding the relative importance of social support is potentially important for clinical practice insofar as such knowledge could enable clinicians to assess the extent to which they should encourage the involvement of significant others in the audiologic rehabilitation process.

STUDY 1 Study 1 set out to investigate the role of perceived social support in hearing aid satisfaction.

METHODS Participants Participants were recruited concurrently from a clinical and from a laboratory sample of volunteers. Those recruited from audiology clinics were participating in a larger study investigating attitudes toward hearing health care. Advertisements for that study were placed in the waiting rooms of 18 public and 50 private practice audiology clinics across all 10 provinces of Canada. Participants were also recruited from a pool of adults from the local community who had volunteered for research conducted at the Human Communication Laboratory at the University of Toronto Mississauga. Participation was limited to those individuals who were 18 years of age or older and who had started learning English before the age of 10 years. Of the 180 participants who reported owning at least one hearing instrument, we report on the responses from 173 (103 males; 70 females) adults (x age = 68.9 years; SD = 13.4 years; ­minimum = 19 years; maximum = 91 years). Seven individuals were excluded from further analysis due to missing data for one or more of the study instruments examined in this study. A total of 46 and 127 participants were drawn from the laboratory and clinic-based locations, respectively.

Procedures Participants were asked to complete a battery of questionnaires. Participation could be completed either online or on

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paper and returned to the experimenter by the mail (questionnaire packages were available with the front office staff of the clinic). The online version of the survey was created using Lime Survey software (www.limesurvey.org). The survey package took approximately 45 minutes to complete. The 46 participants recruited from the university laboratory completed a paper copy of the questionnaires on site. Of those recruited from the clinics, 74 participants completed a paper copy of the questionnaires and returned it to us by mail, and 53 completed the questionnaires on the Internet. The study was approved by the Institutional Ethics Review Board of the University of Toronto.

Measures Participants were asked to complete a number of self-report questionnaires on hearing aid satisfaction, hearing handicap, perceived social support, personality, quality of life, and demographic characteristics (e.g., age, income). The measures used in this study were the following: Satisfaction With Amplification in Daily Life  •  (SADL; Cox & Alexander 1999): The SADL measures satisfaction with hearing aids by asking individuals to rate 15 items on a seven-point Likert scale that contains response options ranging from “Not at all (1)” to “Tremendously (7).” Responses can be analyzed to obtain a global score for hearing aid satisfaction, and subsets of responses to the 15 items can be used to obtain scores for four different subscales (Positive Effects, Service and Cost, Negative Features, and Personal Image). Each subscale represents a different aspect of hearing aid satisfaction. For example, the Personal Image subscale includes questions on appearance when wearing hearing aids, as well as whether hearing aid use affects how the user believes himself/herself to be perceived by others (Cox & Alexander 1999). This instrument also includes four additional items concerning the individual’s experience with their current hearing aids, lifetime experience with hearing aids, daily hearing aid usage, and degree of hearing loss (Cox & Alexander 1999). The SADL is an outcome measure commonly used in both clinical and research settings (see Wong et al. 2003). Moreover, results from the SADL were found to have a strong positive correlation with another well-known measure of hearing aid satisfaction, the MarkeTrak-IV Satisfaction survey (r  =  0.75, p < 0.01; Humes et al. 2002). The Hearing Handicap Inventory for the Elderly— ­Screening  •  (HHIE-S; Ventry & Weinstein 1982): The HHIES is a 10-item measure of social and emotional effects of hearing loss with higher scores indicating more hearing handicap. Participants are asked whether they experience hearing or hearing-related difficulties and respond with a “yes,” “sometimes,” or “no.” The Duke-University of North Carolina Functional Social Support Questionnaire  •  (DUFSS; Broadhead et al. 1988): Perceived social support was measured using the DUFSS, a validated 8-item questionnaire that is commonly used in research investigating the effects of perceived social support (e.g., item 1  =  “I have people who care what happens to me”; item 2 = “I get love and affection”; item 7 = “I get useful advice about important things in life”). Note that the

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DUFSS is not domain-specific so it does not specifically target individuals with hearing impairment. Responses are made on a 5-point Likert scale with higher values corresponding to greater perceived social support (i.e., “1” = “Much less than I would like”; “5” = “As much as I would like”). The DUFSS can be analyzed to yield scores on two subscales, “Confidant Support” and “Affective Support.” Confidant support refers to having someone with whom to discuss important and personal matters, whereas affective support refers to being cared for emotionally. The Big Five Inventory  •  (BFI; John et al. 1991): The BFI is a 44-item assessment that measures personality dimensions (Extraversion, Agreeableness, Conscientiousness, Neuroticism or Emotional Stability, and Openness to Experience) according to the Big-Five model of personality, a wellestablished and validated model of personality that describes five dimensions of human personality that determine, in part, how a person will behave, feel, and think across situations (McCrae & Costa 1987). Individuals who have high levels of Extraversion are generally talkative and highly sociable. Agreeableness can be described as how an individual view themselves in relation to others. An individual who possess a high level of Conscientiousness behaves in a manner that adheres to social rules and norms. In general, Neuroticism refers to the experience of negative emotions, such as the tendency to worry and to feel self-conscious. Finally, Openness to Experience include such traits as having a wide range of interests, a high degree of originality, and an active imagination. Respondents who score high on this dimension will describe themselves as being forgiving and trusting of others. Participants are presented with 44 descriptors and indicate the extent to which they think the item describes themselves on a Likert scale from 1 “Disagree strongly” to 5 “Agree strongly.” The BFI is a popular (e.g., cited in over 1000 publications) instrument to measure the Big-Five personality constructs because the psychometric properties of the instrument are excellent, and the instructions are considered straightforward and suitable for use on the Internet (Srivastava et al. 2003). The Health-Related Quality of Life Scale  •  (CDCHRQOL-14; Centers for Disease Control and Prevention 2011a): The CDC-HRQOL is a 14-item questionnaire that is used to collect information on an individual’s health and the effect of any health conditions on daily life. Items vary in their response options, but the main outcome measure is the number of unhealthy days, a composite of the number of days in which an individual experiences poor physical and/or mental health during the last 30 days (Centers for Disease Control and Prevention 2011b). This measure has been validated in both clinical and nonclinical samples of adults (Moriarty et al. 2003). In addition to the HRQOL, we presented a single item assessing quality of life (“Overall, how would you rate the quality of your life?”), whereby “0” indicated “worst possible” and “10” indicated “best possible.” Finally, participants completed a variety of questions assessing demographic variables (e.g., marital status, education, employment status) and details regarding their hearing instruments (e.g., years of experience using hearing aids). One item assessed the participant’s satisfaction with the hearing clinician who fit their most recent hearing aid(s) on a scale from 1 “Not at all satisfied” to 5 “Very satisfied.”

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RESULTS This section is organized by first providing descriptive statistics regarding the participants and key variables of interest, followed by an account of the predictor variables that were significantly associated with global satisfaction scores on the SADL questionnaire and concluding with a description of the results of a regression analysis designed to examine the extent to which different factors explain variation in satisfaction.

Characteristics of Participants and Key Measures Demographic and audiologic characteristics of the sample can be found in Tables 1 and 2. Descriptive statistics for the key measures from study 1 are summarized in Table  3. In general, participants reported being relatively satisfied with their hearing aids. Mean global SADL ratings in the present study indicated that participants were “considerably” satisfied (x   =  5.11, SD  =  0.81). This result was very similar (i.e., within 0.2 scale points) to global SADL ratings reported by Humes et al. (2002), Hosford-Dunn and Halpern (2000), Souza et al. (2000), and Cox and Alexander (1999).

Results from the DUFSS revealed that, on average, individuals received “almost as much” social support as they would like (x  = 4.18, SD = 0.80). Participants reported an average of 4.15 unhealthy days in the past 30 days, which is less than the average of 5.5 (CI = ±0.0), reported by 1,257,726 adults polled from 1993 to 2001, as part of the Behavioral Risk Factor Surveillance System in the United States (Zahran et al. 2005). Thus, the sample as a whole could be characterized as an older adult sample that is as satisfied as participants in other research investigating satisfaction with hearing aids, receives almost as much social support as they would like, and is slightly healthier than a population-based sample obtained in the United States.

Correlates of Satisfaction With Hearing Aids Pearson product moment correlation coefficients (with Bonferroni corrections for multiple comparisons) between hearing aid satisfaction (as measured using the SADL) and several previously identified correlates of hearing aid satisfaction (i.e., hearing disability, years of experience with hearing aids, daily hearing aid usage, satisfaction with service provider, personality), as well as

TABLE 1.  Demographic characteristics of participants in studies 1 and 2 Variable

Study 1 (N = 173)

%

Study 2 (N = 161)

%

18–30 years old 31–64 years old 65 years and older NR Female Male NR Married/common-law/partnership Widowed Separated/divorced Single Other NR $0–20,000 USD $20,001–40,000 USD $40,001–60,000 USD $60,001–80,000 USD $80,001–100,000 USD $100,001 USD and over Prefer not to answer NR Less than high school High school or equivalent Some college/college degree Some university Undergraduate degree Master’s degree Doctoral degree NR

59.6 33.5 5.0 1.9 32.9 65.8 1.2 41.6 3.1 6.8 46.0 1.9 0.6 34.2 18.0 21.7 13.0 7.5 0.6 3.7 1.2 0 9.3 25.5 12.4 30.4 21.1 0.6 0.6

Asian Black Caucasian Hispanic or Latino Other

46.0 2.5 47.8 1.9 1.9

Age group

18–30 years old 31–64 years old 65 years and older

2.9 26.0 71.1

Sex

Female Male

40.5 59.5

Relationship status

Married Widowed Separated/divorced Single Other NR $0–20,000 CAD $20,001–40,000 CAD $40,001–60,000 CAD $60,001–80,000 CAD $80,001–100,000 CAD $100,001 CAD and over Prefer not to answer NR Less than high school High school or equivalent Some college/college degree Some university Undergraduate degree Master’s degree Doctoral degree Professional degree NR —

66.5 13.3 9.2 8.1 2.3 0.6 7.5 17.3 22.0 16.8 11.0 10.4 12.1 2.9 3.5 23.7 27.7 9.8 16.2 12.7 1.7 2.9 1.7 —

Income

Highest level of educational attainment

Ethnicity

CAD = Canadian dollar; NR = no response; USD = United States dollar.

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TABLE 2.  Audiologic characteristics of participants in studies 1 and 2 Variable Hearing loss

Degree of self-reported hearing loss*

HA use

Daily HA usage

Lifetime HA experience

HA style†

Study 1 (N = 173)

%

Both ears Left ear Right ear NR None Mild Moderate Severe NR Bilateral Unilateral NR None Less than 1 hour/day 1 to 4 hours/day 4 to 8 hours/day 8 to 16 hours/day NR Less than 1 year 1 to 4 years 5 to 8 years 9 years or more NR —

93.6 2.3 3.5 0.6 1.7 14.5 48.6 32.9 2.3 80.9 18.5 0.6 1.2 5.2 5.2 19.1 68.8 0.6 5.8 22.5 20.2 35.3 16.2 —

Study 2 (N = 161)

%

Both ears Left ear Right ear

37.3 40.4 22.4

None Mild Moderate Severe NR Bilateral Unilateral

13.7/22.4 31.7/25.5 33.5/36.6 19.3/13.7 1.9/1.9 34.2 65.8

Less than 1 hour/day 1 to 4 hour/day 5 to 8 hours/day 9 to 16 hours/day More than 16 hours/day

4.3 9.3 31.7 49.1 5.6

Less than 1 year 1 to 4 years 5 to 8 years 9 years or more NR ITC—invisible (1) ITC—visible (2) ITE—partial (3) ITE—full (4) BTE (5) Other, do not know, or NR

23.6 39.8 18.6 16.8 1.2 14.3 22.4 12.4 6.2 40.4 4.3

BTE = Behind-the-ear; HA = hearing aid(s); ITC = in-the-canal; ITE = in-the-ear; NR = no response. *Study 2 (left ear/right ear). †Reported style of hearing aid was recoded from smallest (ITC = 1) to largest (BTE = 5).

variables which have received less attention in previous research (e.g., quality of life, perceived social support) were calculated (see Table 4). In general, for the previously identified correlates of hearing aid satisfaction, the results from study 1 are in good agreement with previous research (Wong et al. 2003). Overall, it was observed that global SADL scores were significantly positively correlated with perceived social support (DUFSS), duration of daily hearing aid use, satisfaction with one’s hearing health care practitioner, and Openness but negatively correlated with Neuroticism. Global satisfaction scores on the SADL were not found to be significantly associated with reported hearing disability (HHIE-S), lifetime years of experience with hearing aid use, age, or either of the quality of life measures (our singleitem global measure or the HRQOL). A second-order partial correlation between the primary variables of interest in the present study (i.e., global DUFSS and global SADL scores) was calculated to determine whether the observed relationship between perceived social support and hearing aid satisfaction was due to a response bias arising from the tendency to respond positively on self-report measures. The results from this analysis indicated that after controlling for acquiescence scores on the BFI (John et al. 2008), the correlation between global SADL and DUFSS scores remains unchanged (r = 0.34, p < 0.01). To assess whether the relationship between perceived social support and hearing aid satisfaction depends on the method of test administration, the sample was split into three groups according to whether the results were gathered from: (1) paper forms completed

on site, (2) paper forms returned via the mail, or (3) the Internet. Second-order partial correlations between global SADL and DUFSS scores were conducted while controlling for acquiescence scores on the BFI. The partial correlations for the three groups all reached significance, r = 0.32, p = 0.03; r = 0.41, p < 0.001; and r = 0.34, p = 0.01, respectively. Thus, the correlations did not depend on the method used to administer the questionnaires.

Stepwise Multiple Regression A stepwise multiple regression analysis was conducted in which global SADL scores served as the criterion variable and variables previously identified as correlates of hearing aid satisfaction (i.e., hours of daily hearing aid usage, satisfaction with hearing health care practitioner, hearing handicap, Openness, Neuroticism), as well as DUFSS and CDC-HRQOL scores were entered as predictor variables. Four variables emerged as significant predictors of global SADL scores: DUFSS score, satisfaction with one’s hearing health care provider, duration of daily hearing aid usage, and Openness (see Table 5). In total, the four variables accounted for 22% of the variance in global SADL scores. The best predictor of hearing aid satisfaction in study 1 was perceived social support, which accounted for 8% of the variance in global SADL scores.

STUDY 2 A sequel study was conducted to replicate and extend the results from study 1. The main goal of study 2 was to determine

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TABLE 3.  Descriptive statistics for variables in studies 1 and 2 Study 1 (N = 173) Variable SADL: global  Positive effects  Services and cost  Negative features  Personal image DUFSS: global  Confidant support  Affective support Age (years) Quality of life HHIE-S/HHIA-S (hearing handicap) HA experience (years) Big-five factors  Extraversion  Agreeableness  Conscientiousness  Neuroticism  Openness HRQOL unhealthy days Satisfaction with hearing service provider APHAB (HA benefit)  Ease of communication  Background noise  Reverberation  Aversiveness

Study 2 (N = 161)

x

SD

x

SD

t Test Statistic

5.11 5.39 4.60 4.24 5.87 4.18 4.09 4.32 68.86 8.18 24.03 10.48

0.81 1.14 1.10 1.54 0.97 0.80 0.88 0.79 13.43 1.27 9.88 10.33

4.55 4.75 4.47 4.19 4.58 3.85 3.81 3.90 32.80 7.49 22.39 2.64

0.84 1.12 1.14 0.95 1.07 0.85 0.89 0.89 13.25 1.77 8.73 2.03

6.20† 5.21† 1.05 0.38 11.55† 3.65† 2.86† 4.52† 24.55† 4.04† 1.61 8.94†

3.32 4.00 3.98 2.46 3.67 4.15 4.35 — — — — —

0.72 0.60 0.63 0.80 0.56 7.69 0.83 — — — — —

3.23 3.63 3.71 2.62 3.49 — — 23.61 21.39 25.23 24.25 −20.68

0.72 0.69 0.68 0.80 0.55 — — 26.36 33.96 26.14 27.44 31.53

1.20 5.21† 3.80† −1.82 2.88† — — — — — — —

*Correlation is significant at the 0.05 level (2-tailed). †Correlation is significant at the 0.01 level (2-tailed). DUFSS = Duke-University of North Carolina Functional Social Support; HA = hearing aid(s); HHIA-S = Hearing Handicap Inventory for Adults (Screening Version); HHIE-S = Hearing Handicap Inventory for the Elderly (Screening Version); HRQOL = Health-Related Quality of Life; SADL = Satisfaction with Amplification in Daily Life.

whether the relationship between perceived social support and hearing aid satisfaction observed in study 1 would also be found in a different sample of hearing aid users not recruited at clinics or at the laboratory but that was instead recruited from a very widely ranging sample of people participating in research on the Internet. By observing a similar pattern of results in a new sample recruited on the Internet, there would be less reason to believe that the relationship between perceived social support and hearing aid satisfaction arose because of the sample composition and recruitment strategy.

METHODS Procedure Participants were recruited using Amazon Mechanical Turk (MTurk), a web-based crowdsourcing Web site that has gained popularity with academic researchers. The MTurk population is composed of anonymous online workers who complete Internet-based tasks in exchange for relatively small sums of money. Overall, the results from several reviews report that the data obtained using MTurk is typically at least as reliable as those obtained using more traditional methodologies (Buhrmester et al. 2011; Casler et al. 2013; Crump et al. 2013; Paolacci & Chandler 2014). Participation was restricted to individuals reporting to be 18 years of age or older, to have a hearing loss, and to currently own at least one hearing aid. Interested individuals were provided with the study web address where the survey could be completed. The survey was designed using

SurveyMonkey (www.surveymonkey.com), took approximately 30 minutes to complete, and participants were paid $1.50 CDN for their time. The study was approved by the Institutional Research Ethics Board of the University Health Network in Toronto.

Participants A total of 203 individuals responded to the survey. Of the 203 respondents, the data from 161 individuals were included for further analysis. The data from 33 participants were excluded because responses were provided to less than 50% of the survey items. Of the remaining 170 participants, the data from nine were excluded because they either did not report that they had a hearing loss (n = 5) or there were discrepancies in their reporting of hearing loss (n = 4; e.g., one of the participants reported a hearing loss in their left ear but reported later in the survey that no hearing loss was present in the left ear).

Materials Participants were asked to complete a total of six questionnaires. The questionnaires assessing satisfaction with hearing aids (SADL), perceived social support (DUFSS), and dimensions of personality (BFI) were identical to those used in study 1. Anticipating that the majority of respondents on MTurk would likely be less than 65 years of age, the Hearing Handicap Inventory for Adults (HHIA-S; Newman et al. 1990) was administered in place of the HHIE-S. In the interest of minimizing the

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TABLE 4.  Correlations of different variables with hearing aid satisfaction (SADL) and perceived social support in study 1

DUFSS: global  Confidant support  Affective support Age HRQOL unhealthy days HHIE-S (hearing handicap) HA experience (years) Daily HA usage Extraversion Agreeableness Conscientiousness Neuroticism Openness Satisfaction with service provider

SADL: Global

SADL: Positive Effects

SADL: Services and Cost

SADL: Negative Features

SADL: Personal Image

0.34† 0.34† 0.29† 0.02 −0.09 −0.09 0.03 0.23† −0.00 0.01 0.10 −0.16* 0.21† 0.33†

0.20† 0.19* 0.19* −0.13 −0.04 0.10 0.26† 0.37† −0.01 −0.02 0.12 −0.09 0.22† 0.31†

0.20† 0.20† 0.18* 0.02 −0.04 −0.06 0.01 0.11 −0.01 0.00 0.07 −0.01 0.13 0.40†

0.31† 0.32† 0.23† 0.11 −0.06 −0.33† −0.20* −0.07 0.05 −0.00 −0.02 −0.27† 0.11 0.08

0.26† 0.28† 0.18* 0.18* −0.14 −0.05 −0.22† 0.05 −0.05 0.08 0.05 −0.04 0.07 0.05

DUFSS: Global

0.13 −0.18* −0.13 −0.09 −0.01 0.16* 0.11 0.16* −0.27† 0.06 0.10

DUFSS: Confidant Support

DUFSS: Affective Support

0.97†

0.89† 0.76†

0.12 −0.19* −0.15* −0.12 −0.02 0.17* 0.10 0.15* −0.25† 0.04 0.09

0.12 −0.15* −0.08 −0.03 0.01 0.11 0.11 0.14 −0.27† 0.10 0.11

*Correlation is significant at the 0.05 level (2-tailed). †Correlation is significant at the 0.01 level (2-tailed). DUFSS = Duke-University of North Carolina Functional Social Support; HA = hearing aid(s); HHIE-S = Hearing Handicap Inventory for the Elderly (Screening Version); HRQOL = Health-Related Quality of Life; SADL = Satisfaction with Amplification in Daily Life.

duration of the survey, the HRQOL was not presented to participants in study 2, but the single-item measure assessing the quality of life was retained. In addition to the measures used in study 1, study 2 included the Abbreviated Profile of Hearing Aid Benefit (APHAB; Cox & Alexander 1995) because previous research has observed a significant correlation between hearing aid satisfaction and perceived benefit (e.g., Wong et al. 2003). The APHAB measures subjective hearing aid benefit by comparing aided listening performance against unaided performance in 24 different listening situations, whereby participants are presented with seven response options ranging from “never” to “always.” A new question was added about style of hearing aid; responses were coded in a rank order from smallest to largest in size and degree of visibility (i.e., in-the-canal [invisible]  =  1, in-the-canal [visible]  =  2, in-the-ear [partially visible] = 3, in-the-ear [fully visible] = 4, BTE = 5). In error, ratings assessing satisfaction with one’s hearing health care practitioner were not collected. Finally, participants completed a modified version of the demographic questionnaire. The modified version contained fewer items in total than the version used in study 1 but contained several new items in an attempt to try to characterize the potentially more widely ranging nature of the sample; for example, one of the new questions asked about

ethnicity (MTurk studies have been observed to be more ethnically diverse than university-based research conducted in most North American universities; Paolacci & Chandler 2014).

RESULTS Characteristics of Participants and Key Measures Demographic and audiologic characteristics of the sample in study 2 are summarized in Tables 1 and 2. The sample in study 2 differed from the sample in study 1 in several notable ways. Overall, the sample from study 2 was younger, more likely to be single, earned less income, was less educated, had more unilateral compared with bilateral hearing loss, and had less lifetime experience with hearing aids than the sample in study 1. Data on race or ethnicity were only collected in study 2, with the largest proportion of participants being either Caucasian or Asian. Descriptive statistics of the measures collected in study 2 are described in Table  3. Similar to study 1, participants indicated a mildto-moderate degree of hearing handicap (x  = 22.4, SD = 8.7 on the HHIA-S), a mean score of 7.5 of 10 (SD = 1.8) on the self-rating of overall quality of life, and that they were considerably satisfied (x  = 4.55, SD = 0.84 on the SADL) with their hearing aid(s), and that they received almost as much social support as they would

TABLE 5.  Study 1: summary of stepwise multiple regression model (N = 173) for predicting ratings of satisfaction with hearing aids Criterion

Predictor

R2

Adjusted R2

R2 Change

Standardized Coefficients: Beta

t

Significance

DUFSS-global Satisfaction with service provider Daily hearing aid usage Openness

0.22 — — — —

0.20 — — — —

0.08 0.07 0.04 0.03

— 0.29 0.22 0.22 0.18

— 3.85 2.86 2.90 2.42

— 0.000 0.005 0.004 0.017

SADL-global (model 4)

Model 1 Predictors: DUFSS (global) (R2 = 0.08). Model 2 Predictors: DUFFS (global), satisfaction with service provider (R2 = 0.15). Model 3 Predictors: DUFFS (global), satisfaction with service provider, daily hearing aid usage (R2 = 0.19). Model 4: F(4,138) = 9.81, p < 0.001. SADL = Satisfaction with Amplification in Daily Life.

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TABLE 6.  Correlations with SADL and DUFSS in study 2

DUFSS: global  Confidant support  Affective support Age Quality of life HHIA-S (hearing handicap) HA experience (years) Daily HA usage Extraversion Agreeableness Conscientiousness Neuroticism Openness APHAB: benefit  Ease of communication  Background noise  Reverberation  Aversiveness HA style‡

SADL: Global

SADL: Positive Effects

SADL: Services and Cost

SADL: Negative Features

SADL: Personal Image

0.51† 0.52† 0.43† 0.19* 0.33† 0.03 0.27† 0.28† 0.20† 0.58† 0.52† −0.46† 0.33† 0.46† 0.34† 0.47† 0.47† −0.27† −0.16*

0.48† 0.48† 0.42† 0.12 0.27† 0.17* 0.31† 0.28† 0.13 0.52† 0.46† −0.35† 0.31† 0.46† 0.32† 0.48† 0.46† −0.33† −0.11

0.34† 0.35† 0.29† 0.05 0.21† 0.01 0.22† 0.22† 0.19* 0.41† 0.38† −0.36† 0.37† 0.24† 0.20* 0.20* 0.26† −0.11 −0.09

0.28† 0.32† 0.19* 0.13 0.23† −0.18* −0.03 0.14 0.18* 0.29† 0.24† −0.29† 0.05† 0.25† 0.18* 0.24† 0.26† −0.07 −0.14

0.38† 0.38† 0.34† 0.32† 0.32† −0.11 0.20* 0.16* 0.17* 0.50† 0.48† −0.44† 0.22† 0.38† 0.28† 0.42† 0.37† −0.18* −0.19*

DUFSS: Global

0.12 0.58† −0.03 0.22† 0.21† 0.35† 0.49† 0.43† −0.46† 0.34† 0.24† 0.16* 0.26† 0.23† −0.12 0.08

DUFSS: Confidant Support

DUFSS: Affective Support

0.98†

0.93† 0.82†

0.13 0.57† −0.06 0.19* 0.18* 0.34† 0.47† 0.41† −0.45† 0.33† 0.22† 0.15 0.25† 0.22† −0.11 0.04

0.11 0.54† 0.02 0.26† 0.23† 0.33† 0.48† 0.41† −0.43† 0.32† 0.23† 0.17* 0.26† 0.22† −0.13 0.15

*Correlation is significant at the 0.05 level (2-tailed). †Correlation is significant at the 0.01 level (2-tailed). ‡Reported style of hearing aid was recoded from smallest (ITC = 1) to largest (BTE = 5). APHAB = Abbreviated Profile of Hearing Aid Benefit; DUFSS = Duke-University of North Carolina Functional Social Support; HA = hearing aid(s); HHIA-S = Hearing Handicap Inventory for Adults (Screening Version); HRQOL = Health-Related Quality of Life; SADL = Satisfaction with Amplification in Daily Life.

like (x  = 3.85, SD = 0.85 on the DUFSS). That said, and as confirmed by independent samples t tests, statistically lower scores were observed in study 2 compared to study 1 on the measures assessing hearing aid satisfaction [t(332) = 6.20, p < 0.001], perceived social support [t(332) = 3.65, p < 0.001], and quality of life [t(287) = 4.04, p < 0.001]. However, a statistically significant difference was not observed with respect to hearing handicap (p > 0.05).

Correlates of Satisfaction With Hearing Aids Pearson product moment correlation coefficients (with Bonferroni corrections for multiple comparisons) for variables in study 2 are summarized in Table  6. Significant correlations were observed between global SADL scores and scores on the DUFSS (including subscales), age, lifetime experience with hearing aids, personality (Extraversion, Agreeableness, Conscientiousness, Neuroticism, and Openness), APHAB-benefit scores, quality of life, and duration of daily hearing aid usage. As in study 1, a second-order partial correlation between global SADL and DUFSS scores was conducted. After controlling for acquiescence scores on the BFI, the correlation between global SADL scores and scores on the DUFSS questionnaire was reduced from r = 0.51 to 0.39 (ps < 0.001), but the correlation remained significant. Note that the difference in the correlations calculated with or without controlling for acquiescence was not significant (p > 0.05). Finally, in a follow-up analysis, to assess whether the relationship between perceived social support and hearing aid satisfaction was different for new and experienced users of hearing aids, the sample was split into those with less than or equal to (n = 18) or more than (n = 143) 5 months of lifetime experience wearing at least one hearing aid. Specifically, a second-order

partial correlation between global SADL and DUFSS scores was conducted while controlling for acquiescence scores. The partial correlation for new users was r  =  0.65, p < 0.01, and for experienced users was r = 0.37, p < 0.001. Therefore, the relationship between social support and HA satisfaction was significant for both groups.

Stepwise Multiple Regression A stepwise multiple regression analysis was conducted, whereby global SADL scores served as the criterion variable and the predictor variables were those previously identified as correlates of hearing aid satisfaction (global APHAB [hearing aid benefit], duration of daily hearing aid usage, lifetime experience with hearing aids, HHIA-S [hearing handicap], Openness, Neuroticism, and hearing aid style), as well as scores on the DUFSS and the quality of life item. Four variables emerged as significant predictors: global DUFSS score, global APHAB-benefit, Neuroticism, and hearing aid style (see Table 7). In total, the four predictors accounted for 43% of the variance in global SADL scores, with the best predictor being the DUFSS, which accounted for 25% of the variance in global SADL scores.

DISCUSSION The goals of the current research were to determine (1) whether there is an observed relationship between social support and satisfaction with amplification, and (2) the relative predictive power of perceived social support on hearing aid satisfaction compared to other variables that have been shown previously to be significant predictors of hearing aid satisfaction.

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TABLE 7.  Study 2: summary of simultaneous stepwise multiple regression model (N = 161) for predicting ratings of satisfaction with hearing aids Criterion

Predictor

R2

Adjusted R2

DUFSS-global APHAB-benefit Neuroticism Style of hearing aid

0.43 — — — —

0.41 — — — —

SADL-global (model 4)

R2 Change

Standardized Coefficients: Beta

t

Significance

0.25 0.12 0.04 0.03

— 0.34 0.29 −0.22 −0.16

— 4.79 4.41 −3.01 −2.61

— 0.001 0.001 0.003 0.010

Model 1 Predictors: DUFSS-global (R2= 0.25). Model 2 Predictors: DUFSS-global, APHAB-benefit (R2 = 0.37). Model 3 Predictors: DUFSS-global, APHAB-benefit, Neuroticism (R2= 0.40). Model 4: F(4,147) = 27.62, p < 0.001. APHAB = Abbreviated Profile of Hearing Aid Benefit; DUFSS = Duke-University of North Carolina Functional Social Support; SADL = Satisfaction with Amplification in Daily Life.

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