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However, as mentioned, peripheral hearing loss is the only one aspect of age-related hearing loss, and therefore also only one of the aspects which result in the oral communication difficulties observed in older adults. There is evidence that auditory rehabilitation programmes which are implemented as additional treatment to the use of hearing aids result in significant improvements in the perception of hearing disadvantage compared to the use of hearing aids alone, 13—15 these sorts of interventions are also more cost effective.

The reasons why patients with hearing loss decide to undergo a rehabilitation programme, decide to enhance their hearing capacity with hearing aids or decide not to accept any form of intervention have also been studied. Twenty-four percent of the patients studied did not pursue the intervention which they had initially chosen, which also reflects that intentions do not always translate into behaviours.

Below we shall review the main modes of hearing rehabilitation and the evidence supporting their use.. Sweetow and Palmer 21 performed a systematic review of the effectiveness of both analytical and synthetic auditory training programmes, and a combination of both, in people between 19 and 85 years of age; only 3 of the studies included older adults. In analytical auditory training, speech was broken down into its parts consonants and vowels , and the objective of this technique was to improve discrimination between parts of speech and their recognition.

Synthetic approximation fundamentally sought to improve listening skills using keys associated with linguistic and contextual redundancy. Therefore sentences are usually the auditory verbal material used. In this review 6 studies were analysed which fulfilled the inclusion criteria. It was found that in general training which used synthetic approximation showed improvements in the perception of speech in the presence of background noise and better use of active listening strategies. However, less evidence was found of the effectiveness of analytical training.

The authors conclude that there is still not enough evidence to assess the effectiveness of individual auditory training programmes.. Group auditory rehabilitation programmes, unlike individual auditory training programmes, are based on guidance and communicational strategies to better confront the lack of social participation. From a clinical perspective, these are usually provided to adults after they have been given hearing aids as supplementary help. The great majority of these programmes are basically group therapy for follow-up after fitting hearing aids..

This type of rehabilitation was initially introduced by Carhart in the Deshon General Hospital as part of the post-World War Two military personnel programme. Group auditory rehabilitation programmes usually include directed classes including information on hearing, loss of hearing, lip reading, communicative strategies, and personal assistance devices.

Some of these programmes also include practice in the use of communicational strategies, the use of relaxation techniques and stress management, psychosocial aspects and the involvement of partners.. Hawkins performed a systematic review in on individual adults with hearing loss in order to determine whether participating in group auditory rehabilitation programmes for hearing aid users translated into self-perceived benefit and satisfaction both short and long term as with hearing aids.

A total of 12 studies fulfilled the inclusion criteria. The majority of the studies showed benefits for group auditory rehabilitation programmes, in terms of reducing restricted social participation. Despite there being an improvement in the use of communicative strategies, the data were limited for personal adjustment and better use of hearing aids and had not been systematically replicated.

Hawkins concluded that few studies were well controlled and that there was variability in the results; therefore, he suggested that randomised clinical trials should be run with adequate numbers of participants.. A recent systematic review undertaken by Chisolm and Arnold, 24 completed between May and August in adult individuals, only included randomised clinical studies, in which measurements were taken to assess the effect of rehabilitation, in terms of reducing restricted social participation and improved quality of life.

Table 1 shows the 10 selected studies. The study with the greatest number of participants identified in this review was by Hickson et al. Fifty-four percent of these older adults had been fitted with hearing aids. ACE is a commercially available programme 26 and has been specially designed for older adults with or without hearing aids. This programme is widely used in Australia and currently has been translated into French Canadian and Swedish, and is therefore applied in these countries as well as in English-speaking countries.

Due to these characteristics, the ACE programme seems to be an effective group auditory rehabilitation programme which could be implemented in older Spanish-speaking adult patients. Therefore, the content of the ACE programme and the scientific evidence of its effectiveness are discussed in greater detail below.. This programme is aimed at older adults with hearing loss and is based on problem-solving strategies. It comprises 6 modules around daily communication activities, which have been demonstrated to be problematic for older adults with hearing loss and their close family members, such as: using the phone, listening to television, going to a restaurant and holding a conversation over dinner.

The specific modules which are dealt with during the programme sessions depend on the communicative needs identified by the group of participants during the first session. This programme is, therefore, less prescriptive than other communication programmes, as the content varies depending on the specific communication difficulties described by participants..

The ACE programme is introduced during the first session and communication needs are analysed where participants discuss the communication difficulties that they encounter on a daily basis as a consequence of their impaired hearing. The needs identified by participants in this session will determine the communication modules to be developed over the following weeks. There is a detailed discussion in each module of the communication activity itself, the source of the difficulties in the activity, possible solutions, practical exercises, exercises to be done at home, and written information.

The ACE sessions are structured to put aspects of daily communication under the individual's control by means of demonstrations, practical exercises, discussions, and problem-solving strategies. The main objectives of this programme are to teach individual problem-solving strategies and approach the use of communication strategies, lip reading, clarification strategies, and assistance technology.

In the time between sessions participants are encouraged to use the new strategies they have learned in their daily communication.. The total number of participants in the research study was ; the mean age was The average audiometric thresholds of the participants , , , and Hz in the better ear was Approximately half of them had been fitted with hearing aids in the past. The participants were assessed before and immediately after they completed the ACE programme. And participants were reassessed 6 months after having completed the ACE programme. All the assessments consisted of self-perception tools.

The results showed significant improvement in participants who completed the ACE programme; these improvements were maintained 6 months after assessments. Furthermore, those participants who were more aware of their hearing difficulties gained greater benefit from the programme.

All of these suggest that implementation of the ACE programme, as well as fitting hearing aids for older adults could be helpful in improving quality of life.. Hearing loss greatly restricts the lives of older adults, leading to limited social participation, and a poorer quality of life. It was detected in a recent critical review that the implementation of hearing aids and the communicational programmes as interventions in the rehabilitation of people over 60 are helpful and works positively to improve their social participation and quality of life; however, availability and adherence remain low.

In this regard, one recent article suggests that the quality of life and adhering to the use of hearing aids in adults over 65 who undertake a group programme of adaptation and monitoring would be similar to individual monitoring; this would save costs in a rehabilitation programme of this type, and would make it possible to improve the availability of these strategies. Various research studies have been completed with a view to determining the effectiveness of auditory training programmes and group auditory rehabilitation which focus on guidance and communicational strategies in adults with hearing loss; both those who are hearing aid users and those who are not.

On the basis of published articles, it seems that synthetic individual auditory training programmes result in improved speech perception skills in the presence of background noise. However, more evidence is required to determine more categorically the effectiveness of individual auditory training programmes..


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Furthermore, there has been a notion for decades for the need to complement the fitting of hearing aids with programmes involving aspects associated with guidance, awareness of hearing and external hearing devices and communication strategies. There are a great many published articles about different types of group auditory rehabilitation programmes, however not all of them show the same results of effectiveness.

In line with the evidence reviewed for this article, this could basically be explained as a bias in the design of the studies. Finally, the studies which included appropriate methodologies to assess the effectiveness of group auditory rehabilitation programmes show that the potential for improving quality of life and reducing the hearing handicap remains limited. A group auditory rehabilitation programme has been identified in this non-systematic review which is used in English-speaking countries that included the greatest number of patients and showed improvements in quality of life, and which could be used in the future for older Spanish-speaking adults with hearing loss..

In conclusion, the use of hearing aids and communication programmes as interventions for people with hearing loss are positive in achieving improved results. Individual rehabilitation programmes principally improve listening and speech perception, whereas group auditory rehabilitation strategies show the potential to reduce limitation of activities and restricted participation and to improve quality of life.

More evidence is required to continue assessing the effectiveness of these programmes.. Acta Otorrinolaringol Esp. ISSN: Previous article Next article. Issue 4. Pages July - August More article options. Download PDF. Corresponding author. This item has received. Article information.

Table 1. List of 10 Studies Selected.. Introduction and objective Hearing loss ranks third among the health conditions that involve disability-adjusted life years. The objective of this review was to determine the effectiveness of auditory rehabilitation programmes focused on communication strategies. Materials and methods This was a narrative revision. Each study was analysed in terms of the type of intervention used and the results obtained.

Results Three articles were identified: one article about the effectiveness of auditory training programmes and 2 systematic reviews that investigated the effectiveness of communicative programmes in adults with hearing loss.

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Conclusions The utility of hearing aid fitting and communicative programmes as rehabilitation options are associated with improvements in social participation and quality of life in patients with hearing loss, especially group auditory rehabilitation programmes, which seem to have good potential for reducing activity limitations and social participation restrictions, and thus for improving patient quality of life.

Palabras clave:. Introduction According to the World Health Organisation, hearing loss ranks third among the health conditions that involve years lived with disability YLD after depression and unintentional injuries. The goal is to promote auditory and communicative training programmes, which have been shown to be effective and which are complemented with the fitting of hearing aids for older adult patients. Hearing Loss in Older Adults Older adults are a particularly significant patient population for ear nose and throat and hearing specialists, as the most commonly observed sensory alteration in this group is hearing loss associated with age or presbycusis.

The signs of changes in peripheral hearing structures are well known 5 ; however, those produced in the central hearing structures are not, which limit rehabilitation interventions in older adults. In this context, oral communication refers to the ability of a person to participate actively and effectively in a conversation in different listening modes. Below we shall review the main modes of hearing rehabilitation and the evidence supporting their use.

Individual Auditory Training Sweetow and Palmer 21 performed a systematic review of the effectiveness of both analytical and synthetic auditory training programmes, and a combination of both, in people between 19 and 85 years of age; only 3 of the studies included older adults. The authors conclude that there is still not enough evidence to assess the effectiveness of individual auditory training programmes. Group Auditory Rehabilitation Programmes Communicational Strategies Group auditory rehabilitation programmes, unlike individual auditory training programmes, are based on guidance and communicational strategies to better confront the lack of social participation.

The great majority of these programmes are basically group therapy for follow-up after fitting hearing aids. Some of these programmes also include practice in the use of communicational strategies, the use of relaxation techniques and stress management, psychosocial aspects and the involvement of partners. Hawkins concluded that few studies were well controlled and that there was variability in the results; therefore, he suggested that randomised clinical trials should be run with adequate numbers of participants. Therefore, the content of the ACE programme and the scientific evidence of its effectiveness are discussed in greater detail below.

List of 10 Studies Selected. Two year follow-up showed no differences between the groups No. The benefit was maintained a year after completing the rehabilitation. Also a decrease in the perception of handicap was also only observed in the auditory training groups measured using the HHIE emotional scale. Primary ear and hearing care training resource: advanced.

Ginebra, Suiza. Stevens, S. Flaxman, E. Brunskill, M. Mascarenhas, C. Mathers, M. Global and regional hearing impairment prevalence: an analysis of 42 studies in 29 countries. Eur J Public Health, 23 , pp. Popelka, K. Cruickshanks, T. Wiley, T. Tweed, B. Klein, R. Low prevalence of hearing-aid use among older adults with hearing loss: the epidemiology of hearing loss study.

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J Am Geriatr Soc, 46 , pp. Van Eyken, G. The complexity of age-related hearing impairment: contributing environmental and genetic factors. Audiol Neurootol, 12 , pp. Gates, J. Lancet, , pp.

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Auditory handicap of hearing impairment and the limited benefit of hearing aids. J Acoust Soc Am, 63 , pp. Nabelek, P. Monaural and binaural speech perception in reverberation for listeners of various ages. J Acoust Soc Am, 71 , pp. Stark, L. Outcomes of hearing aid fitting for older people with hearing impairment and their significant others.

Int J Audiol, 43 , pp. Speech understanding and aging. Working Group on Speech Understanding and Aging. J Acoust Soc Am, 83 , pp. Chang, P. Presbycusis among older Chinese people in Taipei, Taiwan: a community-based study. Int J Audiol, 46 , pp. MarkeTrack V: consumer satisfaction revisited. Hear J, 53 , pp. Issues in the assessment of auditory processing in older adults. Controversies in central auditory processing disorder, pp. Abrams, T. Hnath-Chisolm, S. Guerreiro, S. The effects of intervention strategy on self-perception of hearing handicap.

Ear Hear, 13 , pp. Benyon, F. Thornton, C. Thus, audiologists in South Africa should be trained to provide culturally and contextually relevant aural rehabilitation, including counselling National Department of Health, Sensory management specifically through hearing aids is usually a first step in the intervention process.

Cochlear implants on the contrary are less widely fitted, more costly, need extra training for audiologists and involve other medical professionals, making them less feasible in South Africa. Frequency modulation FM systems are also an effective treatment of peripheral hearing and processing difficulties Sykes, However, there is limited literature on its use in South Africa. It was thus imperative that the current study investigates the provision of each sensory management service and the possible reasons for the limited provision of some of these services.

It appears that audiologists do not provide sufficient communication intervention or mostly only offer specific services that are less time consuming within this category. This could possibly be because of lack of time and being understaffed, besides other challenges. Auditory training involves helping the client learn to effectively listen during conversation while communication strategies training involves training to improve expressive communication skills Tye-Murray, Such training seems to be provided insufficiently in South Africa Naidoo, Reasons behind this are unknown, but it could be because of limited training even though the scope of practice and undergraduate training should include family-orientated approaches to rehabilitation National Department of Health, Use of computer-based interventions could optimise service provision in South Africa.

However, there seems to be limited literature regarding use of such technology locally. Little is known about the use of these programmes in South Africa. Further, it also seems that practical training using these programmes is limited, if at all it takes place in local training institutions. Tele-audiology is another technological development to make audiology services more accessible, especially in remote rural areas Lawrence, ; Nemes, ; Swanepoel, However, it seems to remain unused by many audiologists in South Africa and there is limited literature on its use as a means to provide aural rehabilitation services.

This lack of use could be because of such technology being relatively new in South Africa. Thus, more could be known about it in future, including its possible use in the provision of aural rehabilitation. Lack of resources to provide aural rehabilitation such as time, tools and audiology staff is a global challenge Swanepoel et al. Binzer mentioned the lack of adequate reimbursement for providing aural rehabilitation services as one of the reasons that many audiologists do not provide those services.

In South Africa, socio-economic factors may also impact on service delivery with issues such as unaffordability of transport costs, which could affect attendance to aural rehabilitation sessions for low-income clients. This may have implications for client compliance and benefit from intervention. Little is known about challenges of aural rehabilitation specific to the South African context owing to limited relevant literature. Thus, the current study would provide information about the current status of aural rehabilitation service provision, challenges, interest and related factors as reported by audiologists in current practice.

A total of 45 returned questionnaires were usable. Twenty-three participants Twenty-three Five Most participants had 6—10 years of work experience. The majority were 30 years or younger, and female. The questionnaire was developed using a google form from the Google Drive system Google, It was chosen as it was freely accessible and user friendly for the researcher.

It consisted of 28 items including short, open-ended, multiple-choice, Likert-scale contingent questions, and checkboxes. The questionnaire allowed for different levels of probing within the predominantly close-ended questions, as a large sample size was anticipated. The questionnaire comprised five sections relating to demographics, detailed aspects of service provision, interest and challenges, and training and technological advancements in aural rehabilitation.

Participants remained anonymous as their email addresses were known only to the professional associations who distributed the questionnaire. Participants received an information sheet explaining the nature of the study and their rights as participants, and provided consent before gaining access to the questionnaire. The pilot questionnaires were initially distributed via post together with a short suggestion form for participants to suggest necessary improvements in the structure, understandability and length. The high relevance of the construct to the participants ensured that the construct validity was not compromised.

The use of a subjective questionnaire carries the risk of compromising reliability, thus the researcher relied on the participants being open and honest. However, there were responses through which internal consistency was checked amongst different questions probing the same service.

The pilot study resulted in structural changes to the questionnaire and the use of an online questionnaire to further simplify the data collection process.

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Completed questionnaires were available in the google form for analysis. The professional associations were asked to send a reminder to all their members after a 2-week period. After 5 weeks from the date of questionnaire distribution, data were transferred to the Statistical Package for Social Sciences version 22 for analysis.

Descriptive and inferential statistics were used to analyse the data. The chi-squared X 2 test was used to compare variables of the same service for statistical significance of difference. For instance, a comparison between service provision, interest and challenges for hearing aids was made. The same was done for other services as well.

Therefore, a p -value of more than 0. Thus, there would be a high chance of a relationship between the variables being compared. A statistician advised on the selection of statistical tests suitable for the number of responses and sample size to ensure good quality of data analysis.

While the sample size was relatively small, which could be attributed to limited practice or interest in the topic of aural rehabilitation, results provided an insight into current practices and views. The small sample size and unequal participant numbers precluded analysis such as the difference in practice between public and private audiologists. All services were predominantly provided through individual-based sessions. Hearing aids, communication strategies training and informational counselling were provided by more participants in comparison with other aural rehabilitation services Figure 2.

Hearing aids were the most provided sensory management service by Most The majority Even more Five of the 11 participants provided reasons for not providing aural rehabilitation to adults. For instance, two Limited use of technology to aid aural rehabilitation service provision was reported. The LACE was used by eight Eleven Five participants provided reasons for not using computer-aided programmes, including lack of resources, lack of awareness, and one participant reported using hearing aid software programmes instead, which she thought served the same purpose.

Four Twenty-one participants provided reasons for not using tele-audiology. Six One 4. Contrary to limited service provision, a strong interest was reported.

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For each aural rehabilitation service, the majority of the participants that did not already provide it reported being keen or very keen on providing it. Participants already providing aural rehabilitation were asked if they found each service interesting. Most found each service interesting or strongly interesting Table 1. Overall, most participants reported finding all services strongly interesting except speechreading training and FM systems which the majority of participants found a little interesting. Challenges were experienced with all services as there were more participants that reported experiencing challenges with most services than those that did not Figure 3.

This was expected as more participants reported challenges with the service that was provided by markedly more participants. Twenty-one participants specified challenges experienced. Of these, six Four participants Another two 9. Other challenges reported included affordability, limited time, finances and resources, language barrier, limited skills and knowledge in the field of aural rehabilitation, lack of motivation and poor compliance from clients.

Training for service provision as a challenge was further explored. Responses are seen in Table 2. Overall, most participants felt poorly trained for most aural rehabilitation services. The majority reported being sufficiently trained to provide hearing aids, communication strategies training and informational counselling. However, the majority also reported poor undergraduate training for the provision of FM systems, auditory training, psychosocial adjustment counselling, frequent communication partner training and speechreading training.

Twenty-two A relationship between service provision and interest as well as service provision and challenges experienced were explored to determine if, and the extent to which, these influence service provision Table 3. Overall, there was a significant difference between service provision, interest and challenges experienced by the participants with most services. No statistically significant difference was found between interest and service provision for auditory training and informational counselling, possibly indicating an influential relationship between these variables for each service.

Thus, it is likely there was high numbers of audiologists providing these services owing to their interest in them. Similarly, there was no significant difference between interest and challenges for informational counselling and communication strategies training, indicating a possibility of interest being influenced by challenges or vice versa.

Thus, it was likely that challenges had an impact on how interesting each service is found to be. The study results provided insight into aural rehabilitation even though only 45 participants responded which limited the generalisability of the study. A possible reason for a poor response rate included the questionnaire being accessible only online meaning that some audiologists had to use their own internet and computers without any incentive.

It is also likely that the topic was only of interest to those that responded. However, results provided a starting point from which more research can build on. There was unequal service provision overall with hearing aids, communication strategies training and informational counselling being the most commonly provided services. Amongst sensory management devices, intervention through hearing aids is, and has been, the most provided service traditionally, even in South Africa Carmen, ; Hull, ; Naidoo, ; Ross, Cochlear implants were the least provided sensory management service possibly because of the need for additional training for South African audiologists to practice in this area.

The reason for most audiologists not obtaining such training is to be investigated further. Another South African study Naidoo, that investigated audiology service provision in the country also indicated that Thus, there could be very limited progress and expansion of cochlear implant services in the country as there are still very limited providers of this service. Likewise, FM systems are still provided by only a few audiologists. Although specific reasons for limited provision of FM systems need to be explored, it is suspected that it could be linked to limited provision of auditory processing assessments conducted prior to recommending an FM system Naidoo, Many medical aids in South Africa do not cover the cost of FM systems, further limiting accessibility even in private practice.

Most participants had reported being sufficiently trained for communication strategies training, which is consistent with it being the most provided amongst all communication training intervention services. Auditory training seems to be provided by fewer audiologists over time in South Africa as only Reasons for such a trend are not clear. However, the differences of sample sizes between the two studies could also have contributed to the findings. It is also likely that improved hearing aid technology could make auditory training less relevant as some participants in the study reported.

Wemmer reported that many In the current study, the majority Again, the relevance of speechreading in the current times with better hearing aid technology is also in question. In practice, speechreading training takes much more time and effort in comparison with other communication training services, which could also explain its limited provision locally as audiologists are very limited. Likewise, limited training has possibly led to limited psychosocial adjustment counselling in comparison to informational counselling which is provided by significantly more audiologists.

With regard to other technologies used in aural rehabilitation, tele-audiology and computer-aided aural rehabilitation programmes seem to be used to a limited extent locally as suggested by the current study results. It could be that knowledge and resources necessary to use such a technology are limited in the South African context. However, their use would be better than not, until locally relevant material is available. Most participants did not use tele-audiology because they did not see a need for it and lacked knowledge or the necessary skills to use it.

Other factors that influence the choice of material or technology to use when providing aural rehabilitation services are not known yet, especially in the South African context.

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A strong interest in aural rehabilitation was generally reported. Thus, it is highly likely that most audiologists are interested in aural rehabilitation. However, this interest has not directly translated into increased service provision across all services, possibly because of limited undergraduate training for most services and other factors posing a challenge.

None of the aural rehabilitation services are without challenges with linguistic barriers highlighted. Language barrier and cultural diversity in South Africa are examples of a need to develop contextually relevant resources as research has indicated that the accuracy of a clinical tool could be maintained when made linguistically and culturally relevant Pascoe et al. In addition, challenges such as limited training, time, resource and financial constraints reported are expected to have negative effects on aural rehabilitation service provision. However, challenges and interest in isolation do not themselves have a significant effect in the provision of aural rehabilitation.

Thus, a group of factors significantly affect service provision, and these factors need to be investigated further. The overall findings of this study indicated that although the audiology as a profession has come a long way in the development and provision of particular audiology services, there is still a great need for further development, particularly in training for, developing and providing aural rehabilitation services suitable for the South African context.

Aural rehabilitation services are not provided optimally locally, with some services provided much less than others. This has implications for holistic and comprehensive aural rehabilitation. Challenges are likely experienced by most audiologists but challenges in isolation may not be sufficient to limit service provision. Further, local audiologists most likely have not started using technological developments to their full potential to improve efficiency of service provision.

High interest in aural rehabilitation with limited service provision indicates a need to review various aspects of each service and its relevance to the current times and needs of clients with hearing loss. The study highlights a strong need for improvement in training and service provision for aural rehabilitation to fully benefit adults with hearing loss in South Africa. The study had limited participants and was conducted via a survey where not all participants may have had easy access to the electronic questionnaire, limiting the generalisability of results.

Limited numbers of participants limited the use of inferential statistics where inferences had to be made with caution.