Few of us would question the notion that hearing aids are getting "smarter" and technically more sophisticated all the time. However, while hearing aids may be improving, not so the human beings we're fitting them to. People still come into our clinics angry, confused, anxious and upset, very often needing information and support that transcend the simple provision of hearing aids - no matter how sophisticated. Of course meeting a client's amplification needs is a crucial and necessary first step, but by itself it is too often insufficient to resolve the problems that most hard of hearing people experience. The best opportunity that we as audiologists have in resolving these problems is by addressing them during the hearing aid selection process. What I am suggesting is that a group hearing aid orientation program - basically a short-term aural rehabilitation (A/R) program - be part of the routine "course of treatment" when adults receive hearing aids.

Let's begin by considering prospective hearing aid users. I doubt that very many of them relish the thought of having to wear hearing aids. Most of them have either been dragged or nagged into hearing centers or have experienced such evident hearing difficulties that they feel that they have no choice but to succumb and "get a hearing aid". We know that, on the average, people have been experiencing hearing-related communication problems for about 5 to 7 years before they seek help.

Think about those years. Think about the effects these hearing problems may have had upon the person's family, social circle, and employment situation. Consider the psychosocial problems, the stress, anxieties, and conflicts associated with frequent and erratic communication breakdowns. Most prospective hearing aid users must have experienced many such problems or they wouldn't be seeking help (or others wouldn't be seeking help for them!). We trivialize the sense of hearing and the role that audition plays in our life if we believe that one or two hearing aid individual fitting follow-up appointments during the first 30 days is sufficient for us to resolve the problems wrought by years of poor hearing and an unacknowledged or untreated hearing loss. No matter how advanced and well-fit the hearing aids, they cannot retroactively help people understand how the hearing impairment has affected their current behaviors and relationships. Wearing the aids will not immediately expunge the maladaptive habits formed in those twilight years. We cannot effectively "treat" the person with the hearing loss separate from the very real fact that it is the entire family that has the "hearing problem".

Self-report scales will help us understand the disability and handicapping effects of a hearing loss, and certainly these scales will provide the necessary quantification for evaluating the efficacy of our interventions. These scales cannot, however, impart the real flavor of how a hearing loss can affect a person's life. Even so, the point is almost moot since only about 22% of practicing audiologists routinely administer some sort of hearing handicap assessment scale (Martin, Champlin, & Chambers l998). One-on-one interview sessions by clinicians will get at some of these issues, but this format is not the best way to evoke the full range of feelings and experiences that hard of hearing people and their families describe. Focus groups can provide this kind of information. Recently, the California School of Professional Psychology in San Diego (Sitka 1997a, l997b) reported the results of a major study employing the focus group paradigm.

What the center did was run 13 focus groups of hard-of- hearing (HOH) people across the country, with a total number of 107 participants. Five other focus groups, with a total number of 37 people, were composed of normally hearing family members. All the sessions were video-taped and all comments were transcribed. The purpose was to determine how the hearing loss affected family relationships, social interactions and activities, vocational activities, and general psychosocial well-being - from the perspective of both hard of hearing people and their family members.

To summarize a great deal of information, it was quite clear that the hearing loss had a pervasive impact on all aspects of the lives of all concerned, both the hard of hearing person's and the normally hearing family members. All had a "hearing problem", though only the affected person had a "hearing loss". Miscommunications and misinterpretations in families were common. Accomodations within families ranged from appropriate, inappropriate, to the nonexistent. Hearing family members stated that they learned to cope on their own without help from professionals, and that they were frustrated at the lack of information provided by professional re assistive devices and communication strategies. Basically, they felt ignored, that the focus was on the hard of hearing person and not on how the hearing loss affected the entire family. Families did not generally discuss the impact of the loss in their everyday lives; when the topic was raised, it usually centered on technical assistance and developments rather than emotional and social factors.

The hard of hearing people reported the full gamut of feelings and frustrations that, on the academic level, we all know about but which came through loud and clear in this type of meeting format. Many of them reported feelings of incompetence, guilt, and shame when communication broke down which, for many, led to more passivity and withdrawal. Most of them were apprehensive about informing their employers and co-workers about the hearing loss. They were concerned that they would be viewed as less capable, stigmatized, and denied advancement. For the same reason, most did not ask for accomodations that could be made in the workplace under the ADA. Many were simply unaware of the existence of devices that could help them accommodate to job-related activities. It should be noted that the subjects in this effort were drawn from members of the consumer group Self-Help for Hard of Hearing People; thus it could be assumed that they would be somewhat more assertive and knowledgeable than consumers in general.

The Group Format

What these focus group results reveal is that both hard of hearing people and their families need more information about the impact and remediation of a hearing loss. Furthermore, the responses of the participants clearly show that a group format is not only an efficient way to provide such information but that it can also support more assertive and problem-solving behavior by everyone concerned. Which brings up the issue of time. There's lots we can do, lots we know how to do, but it takes time. The usual hearing aid selection process consists of a comprehensive audiological evaluation, various kinds of speech and real-ear measures, perhaps some sort of loudness scaling test, a hearing aid fitting, and one or two follow-up appointments during the first month with an admonition to "call if you have any problems".

Given the expense, it would be difficult to justify more individual time on a routine basis, yet people need more information, interchanges, and time to adapt to their new situation. And to put this in perspective, because the hearing loss itself has been acknowledged, they are now ready to "hear" about additional measures besides hearing aids that can help reduce the impact of the hearing loss. The group format, with the inclusion of a family member, is both more economical and more effective in many ways. In their classic article, Erdman, Wark, & Montano (l994) present the rationale and advantages of the group format in a rehabilitative as opposed to a diagnostic service delivery model.

"Curative factors that apply in group intervention include altruism, group cohesiveness, universality, sharing information, guidance, catharsis, identification, family and social reenactment, installation of hope, interpersonal learning, self-understanding, and existential factors" (p.57).

In no way am I implying that hearing aids and individual follow-ups do not ameliorate many of the problems caused by a hearing loss. Of course they help, and I'd be the last person to say otherwise. Besides our own common sense, and our day-to-day experiences, we can point to a number of formal studies which have found a reduction in the disability and handicap dimensions subsequent to hearing aid usage. Weinstein (l996) comprehensively summarized the work in this area. The evidence is straightforward and convincing: a hearing aid reduces the handicapping effects of a hearing loss. The point I'm making is even though a conventional hearing aid selection program does reduce the handicap associated with a hearing loss a more extensive follow-up A/R program can do even more.

This, it should be noted, is not a particularly new or adventurous idea. As I well recall, one of the major arguments used 30 years ago by audiologists to "legalize" commercial dispensing was that this would give us a better opportunity to follow-up our patients and to provide them with required A/R services. We felt disconnected from our rehabilitative function when we could only recommend, but not dispense, hearing aids. We wanted to do more, something more in tune with our training and mission as well as something that would distinguish us from traditional hearing aid dealers. It seems, however, that instead of creating a service delivery model consonant with our intentions, we've apparently adopted the same model followed by those we disparaged at the time. But the original rationale for audiologists to dispense hearing aids is still sound; people do generally need more A/R services than they receive with the traditional model, and we are the group that is (or should be) trained to provide these services within the hearing aid dispensing process.

Enriched Post-Hearing Aid Selection Programs.

While the precise details of the programs vary, there is convincing evidence to support the conclusion that people who receive additional pre- and post-fitting counseling services show a greater reduction in the hearing handicap than those who receive less such services.

Twenty years ago, Brooks (l979) examined the extent of handicap reduction and hearing aid usage in two groups of patients, one who received extensive counseling and one which did not. His conclusions are as follows:

Principal conclusion: "although the provision of a hearing aid alone produces some reduction in the handicap, a much greater reduction appears to be achieved by providing some measure of counseling to the hearing impaired subjects." (p. 5)

Surr, Schuchman, & Montgomery (1978) compared hearing aid usage in patients receiving a two week residential program at Walter Reed Hospital to usage by a group that received a traditional 2 hour follow-up program. Those completing the two week program used their aids more often than those receiving the two hour program.

Ten years later, Joe and Sharon Smaldino (l988) essentially reached the same conclusion. All groups receiving hearing aids received demonstrable help, but the handicap for those receiving a month long A/R program was further reduced.

Conclusion: "Because usual brief hearing aid orientation did not produce significant changes in perception of hearing handicap, we can conclude that an orientation by itself may not be enough to help patients maximize benefit from hearing aids." (p.62, i.e. that the brief program was insufficient).

Moving up to more recent times, in a study by Abrams and his colleagues (Abrams, Hnath-Chisolm, Guerreiro, & Ritterman l992), again we find that the conventional way of selecting aids for people does indeed reduce the handicap imposed by a hearing loss, but that the handicap can be further reduced when the selection process includes a short-term A/R program.

Discussion: "A more important finding was that the self-perception of hearing handicap for the counselling-based AR group was reduced more, at least in terms of total score, than for the hearing aid alone group" (p.375).

One final study, while not exactly on this topic, does add evidence for the necessity of following a hearing aid selection with an A/R program. Primeau (l997) looked at people who showed significant reductions in handicap after 6 weeks HA use and those who did not. When he provided additional A/R to those who did not, he was able to increase the number who demonstrated a significant reduction in handicap from 78% to 89%.

Potential Participants

These programs are not only for people who would rate themselves as "dissatisfied" with their hearing aids. Depending upon how consumers rate their satisfaction with hearing aids is, in itself, an inadequate indicator of hearing aid "success", if we define "success" as responding to both the spoken and unspoken needs of our clients. We know that many hearing aid users still report problems with their hearing aids a year or so after receiving them (Alberti et al l984) and that they still felt the need for more information and support at that time. We also know that many family members feel neglected, frustrated, and misunderstood (Sitka 1997a,b) when the focus is only on the hard of hearing person in the usual hearing aid selection process.

Almost half the people responding to the 1997 American Academy of Audiology marketing study reported that they would like more information on how to select, wear and care for hearing aids. Forty percent wanted to learn more about the causes and treatment options of hearing impairments. These may seem like high numbers, yet it is likely that they underestimate the number of people who would like and who could benefit from such information. Many, if not most, of our clients don't know enough to even ask the questions that we may have answers for. They're not going to ask you about the full range of assistive devices out there, for example, since most don't even know these devices exist. They're not going to ask you about communication and repair strategies or the need to know how and when to be appropriately assertive. They may never have heard of the Americans With Disability Act (the ADA), nor appreciate how this law can improve their life situation. Ignorance is not bliss in these instances, just an incubator for continuing conflicts and problems down the road. In short, unless we hold that the hearing aids have completely solved a person's communication problems, everybody whose hearing loss is of sufficient magnitude to require amplification can probably benefit to some degree from additional information or devices.

Objections and Response

When the desirability of group program have been raised in the past, two objections are usually voiced. One is that when they have been offered, relatively few people have taken advantage of the opportunity, even when no cost was involved. Let me address this one first. This does happen and it has happened to me as well. Usually, my response has been, "well you can't bat a 1000, but 333 is not a bad batting average". You offer it, you aggressively push for it, and people make their own decisions. Lately, I've gotten more radical in my thinking on this issue.

If we, as a profession, sincerely believe in the efficacy of a short-term group A/R program within the context of the hearing aid selection process, if we acknowledge the evidence for its value, and its need as expressed by our clients and their families, then we're obligated to provide it. In the same way, and with much the same justification, that we insist we must administer a comprehensive audiological evaluation prior to selecting a hearing aid, we should provide a group A/R program after the aid has been selected. (This is why, for example, we are so adamantly opposed to mail-order hearing aid sales: they do not include what we believe to be crucial pre-fitting hearing aid testing; well, the same logic hold for post-hearing aid selection management). As a profession, we define our own scope of practice, not our patients, not third-party payers, not other professions. If we reach a consensus that everyone who receives a hearing aid must be routinely scheduled for a group A/R program, that it is part of the hearing aid dispensing process in much the same way that immitance measures are a component of an audiological evaluation, then the public will eventually accept this as the recommended procedure. Certainly, many people will object and many will drop out; that's their prerogative. People drop out a chemotherapy course of treatment for cancer as well, and that is also their prerogative. Our obligation is to be professional responsible; we cannot compel adherence.

The second issue that has been raised is a lot easier for me to respond to. That is the economic one; time is money and the extra time invested in such a program is a cost factor, particularly since I suggest that its cost be defrayed by the sale of the hearing aid. Let me give some reasons why I think a required group hearing orientation program can be a cost/effective program, in addition to being a professionally responsible and enjoyable one for the audiologist (Ross, 1997).

1. It will likely reduce the incidence of hearing aid returns. Two recent studies support this assertion. In one, Northern (1998) found, in reviewing over 9000 patient records who received hearing aids from HearX, that the incidence of returns for those patients completing their three hour Hearing Education and Learning program was 3.5% compared to a 12% return rate for those patients who did not take this program. In the second study, DiSarno (1997) found a return rate of only 2% for those patients who completed their 8 hour hearing education program. Clearly, these programs are helping more people accept their hearing aids. Compare these figures to an industry return average rate of 18%. (And this does not include people who reject their hearing aids after the 30 day trial period; this figure also hovers somewhere around 18%.).

2. A well-run group hearing aid orientation program will translate into more satisfied and loyal clients. You're building a client base for the long run.

3. More satisfied users mean more word of mouth referrals, maybe the most effective marketing strategy available. By including family members, you extend the number of potential client contacts. Everybody knows somebody else who needs help.

4. Although the group program is designed to supplement and not supplant individual follow-ups, still the number of unscheduled individual "drop-ins" is likely to diminish.

5. The time frame of the group program permits the demonstration of various kinds of assistive devices, and an opportunity for people to evaluate their own needs and to purchase what they need. This is also a good opportunity to sign people up for a "battery club".

6. During the course of the program, and because of the non-threatening nature of the group dynamics, some monaural users will opt for a binaural fitting.

It is during the course of the post-fitting group sessions, that each person's need for more intensive, personal, therapy can be determined. It is likely that people who have been through a group HA orientation program, with an opportunity to reflect on their communicative performance and personal adjustment in relation to the other group members, would be more receptive to accepting recommendations for personal communication therapy. It is at this stage that a fee for service model would be most appropriate. We would have a stronger case for third-party support if this recommendation were made after completion of the group program. We will have demonstrated our commitment to A/R and our belief in its efficacy if we can point to our own, prior, efforts in this regard.

Finally, when we provide such a program, we are engaged in a fully-rounded professional activity, one in which we have the primary clinical responsibility from diagnosis to treatment. We are the only group that is at least putatively trained to provide these services; if we don't do it, it won't get done. And if we truly "listen" to our patients and their families, we'll see that it needs to be done. Besides, it's fun.

---

Acknowledgement:
This paper was supported in part by Grant #RH133E30015 from the U.S. Department of Education, NIDRR, to the Lexington Center.
References:

• Abrams, H. B. , Hnath-Chisolm, T., Guerreiro, S. M., & Ritterman, S. I. (1992). The effects of intervention strategy on self-perception of hearing handicap. Ear and Hearing, 13(5), 371-377.
• Alberti, P.W., Pichora-Fuller, M. K., Corbin, H., & Riko, K. (l984). Aural rehabilitation in a teaching hospital: Evaluation and results. Annals of Otology, Rhinology, and Laryngology, 93, 589-594.
• American Academy of Audiology, '97 AAA marketing study, Audiology Today, 10(1), 10-14.
• Brooks, D.N., (l979). Hearing aid use and the effects of counselling. Australian Journal of Audiology, 1(1) 1-6.
• DiSarno, N. (l997). Informing the older consumer - a model. The Hearing Journal, 50(10), 49-52.
• Erdman, S. A., Wark, D. J. & Montano, J.J. (l994). Implications of service delivery models in Audiology. Journal of the Academy of Rehabilitative Audiology, 27, 45-60. Martin, F. N. , Champlin, C. A. & Chambers, J. A. (l998). Journal of the American Academy of Audiology, 9, 95-104.
• Northern, J. (l998). Reducing hearing aid returns through patient education. Paper presented at the American Academy of Audiology Convention, Los Angeles, CA
• Primeau, R. (l993). Hearing aid benefit in adults and older adults. Paper presented at the annual meeting of the American Academy of Audiology, Phoeniz, AZ.
• Ross, M. (l997). A retrospective look at the future of aural rehabilitation. Journal of the Academy of Rehabilitative Audiology, 30, 11-28.
• Sitka, C. J. (l997a). Living with hearing loss - focus group results. Part I: Family relationships and social interaction. Hearing Loss, 18(5), 22-28.
• Sitka, C. J. ( 1997b). Living with hearing loss - focus group results. Part II: Career developments and work experiences. Hearing Loss, 18(6), 29-32.
• Smaldino, S. E. & Smaldino, J. J. (l988). The influence of aural rehabilitation and cognitive style disclosure on the perception of hearing handicap. Journal of the Academy of Rehabilitative Audiology, 21, 57-64.
• Surr, R. K. , Schuchman, G. I. & Montgomery, A. A. (l978). Factors influencing use of hearing aids. Archives of Otolaryngology, 104, 732-736. Weinstein, B. E. (l997). Treatment efficacy: Hearing aids in the management of hearing loss in adults. Journal of Speech and Hearing Research, 39(5), S37-S45.