The Use of Handicap Questionnaires in the Pre-Fitting Process



Author: Paul Teie, MS, CCC-A

The decision to purchase hearing instruments (or anything else, for that matter) is an emotional one. Purchases of this importance are seldom made on purely objective grounds. Each purchaser has his or her own personal emotional “agenda”. It is the job of the provider to identify the emotion and to make clear the line between that emotion and the patient’s hearing loss. For this reason, it is important that a positive relationship between the provider and the patient is fostered very early in the process.

Some things we know about our patients even before they step through the office door. This information has been gleaned from years of experience meeting thousands of patients. Still more information can be obtained from marketing research, particularly the MarkeTrak series of surveys that has been conducted by Sergei Kochkin over the last 20 years. This article will focus on some of the common psychological components of hearing loss and the use of some clinical tools to address them.

Denial is not a river in Africa. It is a fact for many of our patients. Denial is not only a factor in recognition of hearing loss, but comes into play in many health-related areas. Who has not heard story after story of individuals with “a little bit of indigestion” who, when finally convinced they should go to the emergency room, find they require multiple bypass heart surgery? Denial is a powerful force that hearing professionals must face every day. From what does its power derive?

It’s helpful to remind ourselves that hearing loss can be easily denied because it can be a subtle disorder. Hearing loss is not all-or-none and it typically progresses slowly over a long period of time. Most people with hearing loss have a significant portion of their hearing spectrum that is normal or near normal. This gives the false impression that all is well. By the time hearing loss has become severe enough to impair communication the sufferer has no recollection of what normal hearing sounded like. This then leads to the natural tendency of most human beings to attribute a problem to an outside source, rather than taking responsibility for it. Hence, “I hear fine. If people would just speak more clearly, I would be OK.”

Even if a person is aware of his or her hearing loss, denial may be a factor due to the implications of having hearing loss. What does hearing loss mean? Hearing loss can be an unwelcome reminder of age and mortality. Wearing hearing aids, then, is a visible sign and an admission of age and loss of vitality.

One of the hearing professional’s greatest allies in overcoming denial is the patient’s family and close friends. These are the people who bear the brunt of the patient’s hearing loss day-by-day. In order to determine the unique dynamic represented by the individuals before you, questionnaires can be used to gather specific information about hearing handicap, expectations or motivation. Over the years several self-report questionnaires have been developed for this purpose. The abbreviated version of the Hearing Handicap Inventory for Adults (HHIA) is one of these useful clinical tools. Recall that the World Health Organization defines handicap as a disadvantage for an individual resulting from an impairment or disability that limits or prevents the fulfillment of a role that is normal, based on their age, gender, social and cultural factors. The HHIA is one of several self reports that can be used to measure the handicapping effects of a hearing loss. The results of the HHIA are used to address some of the psychological affects of hearing loss. Results of the HHIA gathered during the initial office visit from the patient can be compared to the results from the significant others perspective.

The HHIA is a ten-item questionnaire with a version for the patient (“This is how hearing loss affects me.”) and the same questions asked in terms of the significant other (“This is how I see hearing loss affecting him/her.”).1 There is two categories of questions on the HHIA. There are five questions each on the Emotional and Social subscales. The higher the HHIA score is, the greater the recognition that hearing loss is a significant handicapping condition for the patient. This tool can help the audiologist better understand the interaction of the patient’s and the significant other’s response to hearing loss. In addition to the HHIA, the Hearing Handicap Inventory for the Elderly (HHIE) can be used.2 Both the HHIE and HHIA provide valuable pre-fitting information about the patient’s perception on the problem. Figures 1 and 2 are examples of the patient and companion versions of the HHIA. A “yes” response is worth 4 points, a “sometimes” response is worth 2 points and a “no” response is worth 0 points. Although specific normative is available.2 In general terms, if the HHIA score is greater than 24 the patient (or companion) is presenting with a significant hearing handicap. On the other end of the spectrum, a score of 8 or less would be considered a “normal” score and possibly indicative of denial.

Figure 1. The 10-question screening version of the HHIA for the patient.4
HEARING HANDICAP INVENTORY FOR ADULTS - SCREENER INSTRUCTIONS: The purpose of this questionnaire is to identify the problems your hearing loss may be causing you. Circle Yes, Sometimes, or No for each question. DO NOT SKIP A QUESTION IF YOU AVOID A SITUATION BECAUSE OF A HEARING PROBLEM.
E-1 Does your hearing problem cause you to feel embarrassed when meeting new people Yes Sometimes No
E-2 Does a hearing problem cause you to feel frustrated when talking to members of your family? Yes Sometimes No
S-1 Does a hearing problem cause you difficulty hearing/understanding co-workers, clients or customers? Yes Sometimes No
E-3 Do you feel handicapped by a hearing problem? Yes Sometimes No
S-2 Does a hearing problem cause you difficulty when visiting friends, relatives or neighbors? Yes Sometimes No
S-3 Does a hearing problem cause you difficulty in the movies or theater? Yes Sometimes No
E-4 Does a hearing problem cause you to have arguments with family members? Yes Sometimes No
S-4 Does a hearing problem cause you difficulty when listening to the TV or radio? Yes Sometimes No
E-5 Do you feel that any difficulty with your hearing limits or hampers your personal or social life? Yes Sometimes No
S-5 Does a hearing problem cause you difficulty when at a restaurant with relatives or friends? Yes Sometimes No
Denial
In the classic denial scenario, the patient will have a low score (“I don’t think I have a problem with my hearing.”) and the significant other will have a high score (“I am at wits end over his/her hearing loss.”) The most obvious use for this information could be for the hearing professional and the significant other to “gang up” on the patient to force them to submit to hearing aids. A more profitable approach may be to allow the significant other to tell his/her story as to the effect of the patient’s hearing loss on their life. The items on the HHIE questionnaire can be used as starting points for such a discussion.

For example, the provider may ask, “Mr. Jones, you indicated on this questionnaire that you have observed situations where Mrs. Jones hearing loss has caused her embarrassment. Would you mind describing one of those situations?” Then, after the description the provider could follow up the answer and ask, “What was going through your head during that situation?” This will get to the emotion related to hearing loss. It will show the patient the effect their hearing loss is having on others in their life, and demonstrate that their hearing loss can take an emotional toll.

Another way to address denial is to not ask the patient about problematic listening situations until after clinical evidence of hearing loss is available. To ask someone who denies having a hearing loss to tell you about situations where hearing is difficult may yield meager results. However, once the patient has been oriented to what audiometric results may mean, and then being shown in red and blue what the results are for their hearing loss, denial is less defensible and the patient may be more receptive to getting the help they need.

Related to denial of hearing loss is the view that individuals with hearing loss are stigmatized. Hearing aids are outward signs of an otherwise invisible malady. We know from MarkeTrak data that one of the primary concerns of non hearing aid wearers is their appearance. We also know that, for current hearing aid wearers, the appearance of hearing aids is among the least important considerations. Be that as it may, until the patient has experienced wearing hearing aids for himself, he or she is unlikely to be convinced that this is the case. And if hearing aids are not worn, they are doing no one any good. Consequently, when appearance is an issue, it is the provider’s job to prescribe the most discreet hearing aid style that is appropriate for the hearing loss.

We are fortunate to dispense hearing aids in an era in which we have such a great variety of discreet hearing aid styles available for such a considerable range of hearing losses. These include CICs, power CICs, slim-tube receiver-in-the-aid (RITA) mini-BTEs, receiver-in-the-canal (RIC) mini-BTEs, and now invisible-in-the-canal (IIC) instruments that are seated deep within the ear canal. With so many tools at our disposal, only the most severe hearing losses cannot be fit with a discreet style option.

Denial is not the only psychological factor we encounter. It is recognized that hearing loss has significant effects on an individual’s personality.3 Among these effects are paranoia, irritability, domineering, and insecurity. Many of these result from maladaptive communication strategies. Let us take some time to reflect on the origins of these personality traits in hearing impaired individuals, and how these traits can affect our patients’ interactions with us.

Figure 2. The 10-question screening version of the HHIA for the companion.4
HEARING HANDICAP INVENTORY FOR ADULTS - SIGNIFICANT OTHER SCREENER INSTRUCTIONS: The purpose of this questionnaire is to identify the problems your hearing loss may be causing you. Circle Yes, Sometimes, or No for each question. DO NOT SKIP A QUESTION IF YOU AVOID A SITUATION BECAUSE OF A HEARING PROBLEM.
E-1 Does your hearing problem cause your spouse to feel embarrassed when meeting new people? Yes Sometimes No
E-2 Does a hearing problem cause your spouse to feel frustrated when talking to members of your family? Yes Sometimes No
S-1 Does a hearing problem cause your spouse difficulty hearing/understanding co-workers, clients or customers? Yes Sometimes No
E-3 Does your spouse feel handicapped by a hearing problem? Yes Sometimes No
S-2 Does a hearing problem cause your spouse difficulty when visiting friends, relatives or neighbors? Yes Sometimes No
S-3 Does a hearing problem cause your spouse difficulty in the movies or theater? Yes Sometimes No
E-4 Does a hearing problem cause your spouse to have arguments with family members? Yes Sometimes No
S-4 Does a hearing problem cause your spouse difficulty when listening to the TV or radio? Yes Sometimes No
E-5 Do you feel that any difficulty with your hearing limits or hampers your spouse'spersonal or social life? Yes Sometimes No
S-5 Does a hearing problem cause your spouse difficulty when at a restaurant with relatives or friends? Yes Sometimes No
Paranoia
Many of our patients display some level of paranoia. Throughout their daily lives, people with hearing loss find themselves in situations in which they are unable to hear nearby conversations. Consequently, they may feel they are being left out of conversations, or that they are the subject of the unheard conversation. This can cause mistrust and suspicion. Such a person may be particularly suspicious of anyone trying to “sell them something”.

The best approach to the suspicious or distrustful patient is for the hearing professional to be as professional, forthcoming, and transparent as possible. Use of a standardized protocol can offer credibility in this regard. Clear and simple communication without resorting to off-putting jargon is also helpful.

The simple step of describing the audiogram before a hearing test can be helpful. To the suspicious individual, describing the severity of an audiogram after the hearing test has been administered may appear too convenient. Describing the audiogram before the hearing test offers more credibility to the results.

Bright Ideas
  • Encourage new patients to bring a companion to their first appointment with you. Recent data suggests that companion attendance boosts acceptance of your recommendation by 50%.
  • Administer the HHIE/A to the patient prior to their visit with you in the clinic. Consider posting the HHIE/A on your website and encourage patients to complete the questionnaire prior to their visit with you. According to a recent post on AudiologyOnline on January 24, 2011, there is no copyright infringement issues to be concerned about if posted the HHIE/A on your website.
  • An electronic version of the HHIA is available for download from www.audiologyawareness.com
  • Hone your motivational interviewing skills. Conduct a Google search on motivational interviewing and amplification. There are some excellent resources available. Look for papers authored by Michael Harvey, PhD., who’s a recognized authority on this topic within the profession.
Anxiety
Hearing loss is stressful. Having to continually struggle to hear, to be frustrated when they do not understand, to ask for repeats, to be anxious about missing something important, can wear at a person and make them cantankerous, cranky, short-tempered, or impatient. We all have any number of patients who display some of these characteristics.

The first thing we can do to facilitate encounters with such people is to make the situation as stress-free as possible. Speak slowly and clearly (not loudly) and use a very active mouth and lips to assist the patient with speech reading. After the hearing test, counsel the patient while he or she is wearing demonstration hearing aids so that you can be understood clearly. This demo, which is initially approached as a way to facilitate counseling, can later transition to a demonstration of the features of the hearing aid.

Expressing a sincere empathy for the frustration and anxiety attendant to hearing loss can be very welcome to the hearing impaired person. Name, acknowledge and express appreciation of your patient’s feelings, as in: “I can see how that situation might be frustrating to you. If I could show you something that would help you understand in that kind of situation, is that something you would be interested in?”

Domineering
This trait usually results from a maladaptive communication strategy. The domineering person has learned that, if he or she is talking, s/he does not have to listen and risk mis-hearing. This person learns to dominate conversation, so as not to make a communication mistake. In some instances this type of person is simply extremely talkative and just needs to be focused. In other instances, this type of person can become overbearing and domineering. These can be very challenging patients.

The most useful approach to the latter type of domineering personality is to resist the impulse to respond in kind. Escalation can easily result in anger and an irate attitude. Offer little resistance, while keeping the patient focused on the difficulties his hearing loss is causing him and his family and the solutions you have to offer.

Insecurity
Sometimes a person has been embarrassed by their hearing loss so many times that they become timid. Too many times they have mis-heard what is said or not gotten the punch line of a joke. They have been repeatedly embarrassed and humiliated and do not wish to again put themselves in that position, becoming timid and insecure.

For hearing impaired people, communication requires confidence. It is important that hearing impaired people occasionally take a risk and make an informed guess as to what has been said. Consequently, timidity can interfere with communication.

Insecure, timid individuals may also have difficulty making decisions. For that reason, it is particularly important for them to have close friends or supportive family members accompany them to their hearing appointment. In order to assist them in making a decision, it may also be useful to limit the number of hearing aid options from which they have to choose.

An awareness and insight into the psychology of the individual patient can facilitate positive outcomes for the patient and for your office. Awareness and insight into the demographics and attitudes of hearing impaired people in general can also inform our approach to the hearing aid market, as well as to the patient before you. The judicious use of questionnaires like the HHIA can bring a level of precision to the initial intake interview with patients suffering from the untreated consequences of hearing loss.    
References
  1. Ventry, I. & Weinstein, B. (1982). The Hearing Handicap Inventory for the Elderly: A new tool. Ear and Hearing, 3, 128-134.
  2. Newman, C. W., Weinstein, B. E., Jacobson, G. P., & Hug, G. A. (1990). The Hearing Handicap Inventory for Adults: psychometric adequacy and audiometric correlates. Ear and Hearing, 11, 430-433.
  3. National Council on Aging: Consequences of Hearing Loss. 1999 Report
  4. Newman, C. & Weinstein, B. (1988). The hearing handicap inventory for the elderly as a measure of hering aid benefit. Ear and Hearing, 10, 190-191.
Paul Teie is a Regional Training Coordinator for Amplifon USA. He can be reached at paul.teie@amplifon.com.