The effects of a sound awareness pre-fitting intervention:A randomized controlled trial

MARIE OBERG1,2, GERHARD ANDERSSON2,3, GUNILLA WANSTROM4 &

THOMAS LUNNER1,5

1Department of Clinical and Experimental Medicine, Division of Technical Audiology, Linkoping University, 2The Swedish

Institute for Disability Research, Orebro and Linkoping University, 3Department of Behavioural Sciences and Learning,

Linkoping University, Sweden, 4Hearing Clinic, University Hospital, Linkoping, Sweden, and 5Oticon A/S, Research Centre

Eriksholm, Snekkersten, Denmark

AbstractThe objective of the study was to evaluate the effects of an individual pre-fitting intervention for first-time hearing aid users.Thirty-eight hearing impaired adults were randomly assigned to a sound awareness pre-fitting intervention (n�19) or to acontrol group (n�19). The purpose of the sound awareness training was to facilitate the users’ acclimatization to amplifiedsound. The pre-fitting intervention consisted of three visits and was followed by conventional hearing aid fitting that wasidentical for both groups. Standardized questionnaires were administered before and after the pre-fitting intervention, afterthe conventional hearing aid fitting, and at a one-year follow-up. The follow-up also included a clinical assessment by meansof a telephone interview performed by an independent audiologist. The pre-intervention did not result in any majorimprovement over and above the control group. However, improvements were found for both groups following hearing aidfitting. In addition, most participants were considered as successful users in the interview. Future research should targetindividuals in need of extended hearing aid rehabilitation.

Key words: hearing aids, participation restriction, one-year follow-up

Introduction

A well known problem for clinicians in consultations

with first-time hearing aid users is the complaint of

novel and loud sounds (1,2). For example, Jenstad

et al. (1) showed that the most frequent complaint

from users was that the hearing aids were too loud.

First-time users are often overwhelmed by the many

‘new’ sounds and are unaware that all sounds will be

amplified by the hearing aids, which sometimes

contradicts their expectations that only the most

important signals, such as speech, will be amplified.

Exaggerated expectations regarding the capacity of

digital hearing aids to handle and filter sounds can

make this even more of a contradiction for them.

Fortunately, this does not have to be an unsolvable

problem, as many first-time hearing aid users become

used to the novel sounds and increasingly accept

them. However, for some this does not occur auto-

matically and without effort (or even some annoy-

ance). It is possible that counselling can foster a more

rapid habituation to the unwanted sounds amplified

by the hearing aid. In this study we developed a sound

awareness training approach which had as its aim to

help the hearing aid user to become used to sounds

gradually and in effect reach acceptance for the new

sounds (3). Counselling might facilitate a good start

of the rehabilitation with increased willingness to use

the hearing aids. In the present study we explored the

potential benefits of sound awareness training as a

pre-fitting intervention.

The literature on pre-fitting counselling is rather

limited and we have identified only four controlled

studies where the intervention preceded conventional

hearing aid fitting (4�6, Oberg et al., unpublished

observation). As conflicting results have been found it

is not possible to draw any conclusions from the

limited evidence base. Moreover, two of the studies

are more than 20 years old. In the study by Brooks (4),

where the pre-fitting intervention consisted of home

visits, the treatment group showed significant im-

provements in terms of increased hearing aid usage

and also greater reduction in social hearing handicap.

Norman et al. (5) failed to show any differences in

Correspondence: M. Oberg, Department of Clinical and Experimental Medicine, Division of Technical Audiology, University Hospital, S-581 85 Linkoping,

Sweden. E-mail: marob@inr.liu.se

Audiological Medicine. 2008; 6: 129�140

(Accepted 19 February 2008)

ISSN 1651-386X print/ISSN 1651-3835 online # 2008 Taylor & Francis

DOI: 10.1080/16513860802042062

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hearing aid usage, benefit and satisfaction between

their pre-fitting group and a control group. Brooks

and Johnson (7) argued that the pre-fitting visit

established a personal relationship which made the

users more relaxed, reduced their anxiety, and also

enhanced their receptiveness. In a study by Kemker

and Holmes (6), pre-fitting and post-fitting counsel-

ling were contrasted. Results showed that user

competency with the hearing aids was attained more

efficiently following pre-fitting counselling. Kemker

and Holmes (6) also stressed that previous research

had not addressed the effectiveness of pre-fitting

hearing aid orientation, whereas in other health care

fields the effectiveness of pre-education counselling

has been demonstrated by reduced anxiety and

increased coping ability in well prepared patients

(8,9).

In a recent study by our research group a pre-

fitting intervention targeting the users’ own adjust-

ments of amplification, we found some immediate

effects, but there were no clear transfer effects once

the hearing aid had been fitted (Oberg et al.,

unpublished observation). Little is known from

research about the value of increased own activity

in the audiological rehabilitation process. Eriksson-

Mangold et al. (10) developed an Active Fitting

programme of hearing aids (AF) with the purpose to

make the hearing impaired individuals more active

and responsible for their own hearing aid rehabilita-

tion. The users were encouraged to use the aids in

specified situations and recognitions of sounds and

judgements about hearing aid benefit, sound com-

fort and their own reactions were noted in a diary.

Results showed that the subjects became more

positive about their aids, the fitting procedure, and

their performance as hearing aid wearers. They also

expressed a more realistic view of the hearing aid.

Eriksson-Mangold et al. (10) included own activity

and a kind of sound awareness training in the

individual hearing aid fitting procedure. In the

present study we tested if more specific sound

awareness training could be delivered prior to the

hearing aid fitting. In this approach sound awareness

training was put forward as an educational vehicle to

better acclimatize the users for new, sometimes also

perceived as unimportant, sounds which might make

the users better prepared for the forthcoming con-

ventional hearing aid fitting. The analyses of sounds

also might make the users more curios about sounds,

which possibly could increase their willingness to

start using their hearing aids. In summary, the

purpose was to provide the users with a good start

with the audiological rehabilitation, focusing on their

own activity and increased participation. Stephens

and Hetu (11) described audiological rehabilitation

as a problem solving exercise to reduce disability and

handicap, and the intention with the pre-interven-

tion was to facilitate this problem solving.

Due to the conflicting results of pre-fitting inter-

ventions and due to lack of well-designed interven-

tions in general (12), this study was designed as a

randomized controlled trial, with a one-year follow-

up, where participants were recruited consecutively

from the waiting list at the hearing clinic.

The first aim of the study was to investigate the

immediate effects of the intervention compared to a

control group. It was hypothesized that the pre-

fitting intervention would lead to reduced residual

activity limitation and residual participation restric-

tion and increased psychosocial well-being (in terms

of reduced symptoms of anxiety and depression).

The second aim was to investigate residual benefits

of pre-fitting once all participants had received

hearing aids. We expected that the previous sound

awareness training would positively affect hearing

aid benefit, frequency of use, hearing aid satisfac-

tion, psychosocial well-being (anxiety and depres-

sion), activity limitation and participation

restriction, over and above the effects of hearing

aid fitting. In effect, and given the long-term follow-

up at one year post-fitting, the present study design

will answer the question whether there is any added

value of providing a sound awareness pre-fitting

intervention before the actual hearing aid fitting.

Material and methods

Participants

Forty-nine hearing impaired adults were recruited

consecutively from the waiting list at the University

Hospital in Linkoping, Sweden. When recruited, the

participants received information about the research

project and the procedure of randomization either to

the Sound Awareness method (SA) or to treatment as

usual (i.e. control group). Inclusion criteria were:

Symmetric sensorineural mild (PTA 26�40dB) to

moderate (PTA 41�60dB) hearing loss (13), first time

hearing aid user, aged 20�80 years, good general

health and fluent in Swedish. Participants with

possible cognitive deficits (e.g. dementia) were ex-

cluded if they had low scores (11 or less) on the

Controlled Oral Word Association Test (COWAT;

(14). Eight individuals declined to participate. Only

one gave a reason, which was lack of time. Forty-one

individuals were invited for an initial visit but two

individuals declined participation at the initial visit.

For one individual, this was before randomization,

because he thought the questionnaires were too

extensive. For the second it occurred after randomi-

zation, the reason given being lack of time to follow

the schedule for the visits. One individual randomized

130 M. Oberg et al.

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to control group decided not to participate the day

before the start of the conventional hearing aid fitting

because of low motivation. There were 19 partici-

pants in the treatment group, 12 men and 7 women,

with a mean age of 67.1 years (SD�7.9). In the

control group there were 19 participants, consisting

of 13 men and six women with a mean age of 65.5

years (SD�6.9). Mean four-frequency (0.5, 1, 2, 4

kHz) pure-tone average (PTA) for the better ear was

35.6dB HL (SD�7.1) and 35.6dB HL (SD�7.9)

for the treatment group and the control group,

respectively. There were no statistically significant

between-group differences in age, gender or hearing

threshold. Demographic characteristics of the parti-

cipants regarding marital status and duration of

hearing loss showed no significant differences. More-

over, there was no difference in scores for Sense Of

Coherence (SOC) (15) between groups. All partici-

pants were informed about the one-year follow-up at

the beginning of the intervention. Three participants

did not complete the one-year follow-up. One in-

dividual in the SA group had died, and one in each of

the two groups declined further participation.

An overview of the test procedure is found in

Figure 1.

After randomization the treatment group imme-

diately started the intervention (the sound awareness

training) and the control group was informed that

they had been allocated to the group who would

receive their hearing aids later. The conventional

hearing aid fitting procedure started at the same time

and was identical for both groups. The hearing aid

fitting included three follow-up visits every second to

third week (if desired by the user), and the comple-

tion of the rehabilitation took place approximately

nine weeks after the first fitting session.

Questionnaires

Eight questionnaires were used to evaluate hearing

aid outcomes as well as psychosocial well-being. The

instruments were regarded as short enough and

simple enough to fill out and to be appropriate for

clinical use. Moreover, we favoured validated ques-

tionnaires evaluating perceived hearing aid benefit,

expectation of and satisfaction with hearing aids,

perceived hearing handicap and the use of different

communication strategies. The hearing specific

questionnaires used were the Expected Conse-

quences of Hearing Aid Ownership (ECHO) (16),

the Satisfaction with Amplification in Daily Life

(SADL) (17), the Hearing Handicap Inventory for

the Elderly (HHIE) (18), the Communication Stra-

tegies Scale (CSS) (19), and the International Out-

come Inventory for Hearing Aids (IOI-HA) (20).

The ECHO-SADL, the HHIE and the CSS are also

divided into subscales. The ECHO-SADL consists

of four subscales: Personal Image (PI), Positive

Effect (PE), Negative Feature (NF) and Service

and Costs (SC). The HHIE contains the subscale

Social (S) and the scale for Emotional (E) hearing

handicap and in the CSS the three subscales are

divided into Maladaptive (M), Verbal (V) and Non-

verbal (NV) strategies.

To evaluate psychosocial well-being, we used the

Hospital Anxiety and Depression Scale (HADS)

(21) to assess symptoms of anxiety and depression,

and the Sense Of Coherence scale (SOC) (15) to

assess the individual’s ability to feel in control over

their present situation. All hearing specific ques-

tionnaires have been translated into Swedish pre-

viously, and the psychometric properties of these

have been reported (22). Finally, the Client Oriented

Scale of Improvement (COSI) (23) was used as a

part of the conventional hearing aid fitting proce-

dure.

Speech recognition measurements

Assessment of speech recognition in noise and quiet

was performed, using lists with 50 phonemically

balanced monosyllabic words. When testing in noise,

a fixed speech to noise ratio of �4dB was used (24).

Speech recognition was measured as the percentage

of correctly recognized words.

Speech recognition was also measured using

sentences in background noise. This test yields the

speech to noise ratio (SNR) required for 50%

recognition of test words using lists of ten low-

redundancy five-word sentences in an adaptive test

procedure (25) (results will not be reported).

Sound awareness procedure

The pre-fitting intervention consisted of three visits.

The first two visits occurred once a week and the third

after 14 days. Each visit in the clinic consisted of

different listening exercises. The first week was with-

out amplification. The following sessions were per-

formed with amplification and the participants were

recommended to listen both with and without ampli-

fication when evaluating different sounds in their

daily environment. The participants were fitted with

an experimental aid. This was a body worn processor

connected with cords to two BTE hearing aids. The

experimental aids were programmed with an initial

setting that corresponded to the principles of the ASA

fitting rationale†, originally developed for the Oticon

DigiFocus† (26�28). For the first week with ampli-

fication participants were instructed to analyse sepa-

rated, unsophisticated sounds such as one speaker,

sound of a newspaper or birds. The two following

Sound awareness pre-fitting intervention 131

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weeks included listening tasks for more complex

sounds and the participants were encouraged to

gradually seek out several different environments

and analyse and write down their experiences. All

participants were provided with a diary where com-

ments about the loudness and the characteristics of

Assessed for eligibility n = 49

Included n = 41 Baseline

Informed consent, interview, audiometry COWAT, HHIE, ECHO, CSS, HADS, SOC

Randomization n = 39

Treatment Sound-awareness n = 19

Sound-awareness Visit 1= Sound awareness- excersise- without HA Visit 2= Sound awareness-simple sounds- with HAVisit 3=Sound awareness-complex sounds-with HA

Completion Sound-awareness Week 6 HHIE, ECHO, CSS, HADS (Pre-HA)

Instrument selection

n = 19

HA-fitting Counselling, COSI

Two follow-up visits Week 10-15

Counselling, fine tuning, speech recognition

Completion of HA fitting Week 18Fine-tuning, speech recognition

HHIE, SADL, CSS, HADS, IOI-HA (Post-HA)

n = 18

One-year follow-up Fine-tuning, audiometry, speech recognition,

Telephone interview HHIE, SADL, CSS, HADS, IOI-HA (Post one year)

n = 16

Control group n = 20

Control group Week 6 HHIE, ECHO, CSS, HADS (Pre-HA)

Instrument selection

n = 19

Two follow-up visits Week 10-15 Counselling, fine tuning, speech recognition

Completion of HA fitting Week 18Fine-tuning, speech recognition

HHIE, SADL, CSS, HADS, IOI-HA (Post-HA)

n = 19

8 declined participation

2 dropped out

1 died

HA-fitting Counselling, COSI

One-year follow-up Fine-tuning, audiometry, speech recognition,

Telephone interview HHIE, SADL, CSS, HADS, IOI-HA (Post one year)

n = 18

1 denied- Low motivation

1 declined participation

1 died 1 denied-

Low motivation

Figure 1. Flowchart of participants and timeline of the study visits.

132 M. Oberg et al.

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the different sounds could be written down. The

tasks in the diary consisted of both predetermined

listen situations and open tasks, where the partici-

pants described the self-selected sounds in their

environment.

As a complement the participants had access to a

mini-disc on which they could record sounds and

replay them. These recordings facilitated the ana-

lyses and gave opportunity to engage the significant

other in the listening tasks. The participants were

also equipped with a Sound Activity Meter (SAM)

as a complement to the diary (29). The SAM is a

tiny tie-tack sized device designed to be worn on the

collar. It records the quantity (in loudness and in

percentage of time) and the quality of the sounds

(with respect to quiet, noise, speech and speech in

noise) the participant listens to in his/her daily

activities. The characteristics of the sounds, gathered

by the SAM, were downloaded to a computer and

viewed as an ‘envirogram’, shown to the participant.

Hence, the sounds experienced could be compared

and related to descriptions in the diary and to the

recording environments.

Conventional hearing aid fitting

The hearing aid fitting procedure was identical for

treatment and control group. Each visit lasted about

1 h (with extra time for completion of the outcome

measures). At the first conventional hearing aid

appointment, individual goals with the hearing

rehabilitation were assessed by means of the COSI

questionnaire (23). In COSI, the user states one to

five listening situations in which a hearing aid might

help. In this study, the COSI questionnaire was

completed for both unaided (before hearing aid

fitting) and aided (after hearing aid fitting) condi-

tions.

All participants were fitted binaurally with the

digital hearing aids Oticon Atlas Plus, using the

NAL-NL1 prescription. They were allowed to select

in-the-ear (ITE) or behind-the-ear (BTE) types.

The prescription was modified by fine-tuning during

the follow-up visits, according to the user’s subjec-

tive experience of the hearing aids. All follow-up

visits included counselling, assessment of goal

achievement and fine-tuning, if desired, by the user.

The 38 participants were seen by two audiologists.

The audiologist who acted as the counsellor for the

user during the pre-fitting intervention did not

continue as the user’s counsellor during the conven-

tional hearing aid fitting. Hence users switched

audiologists. The participants in the control group

also switched audiologists and the hearing aids were

fitted by an audiologist other than the one they met

at the first, randomization visit.

One-year follow-up with clinical assessment

The one-year follow-up visit included measurement

of pure-tone thresholds and speech recognition. It

also included counselling and fine-tuning, if desired

by the user, and was performed by the same

audiologist who took care of the conventional hear-

ing aid fitting. The one-year follow-up (Post one

year) also included administration by mail of the

same five questionnaires as at the Post-HA assess-

ment and a telephone interview. The interview and

the administration of the questionnaires were per-

formed by an independent audiologist.

The telephone interview was performed as a

complement to the questionnaire data. The audiol-

ogist who performed the telephone interview was

blind with regard to participants’ status, i.e. she only

received name and telephone number of the users

and was also unknown to the users. This audiologist

had no access to the completed questionnaires

(blinded). The interview was performed two to three

weeks after the one-year follow-up visit. The inter-

viewer followed a semi-structured interview guide,

where the items were designed to assess hearing aid

use, hearing aid satisfaction, residual activity limita-

tion, residual participation restrictions, and attitudes

to hearing loss and hearing aids, and use of coping

strategies. These factors were considered important

in the global evaluation of the audiological rehabili-

tation. With regard to the statements collected, the

audiologist assessed the success of the intervention

into three categories: 1) Successful; 2) Success with

limitations; and 3) Unsuccessful. The audiologist

who saw the user at the follow-up visit also assessed

the user according to her evaluation of the user’s

performance.

Statistical analysis

Data were analysed with repeated measures analyses

of variance (ANOVA) implemented as a general linear

model (GLM) with the software package STATIS-

TICA version 7 (30). Each analysis included one

between-group variable (group: treatment vs. con-

trol), one within-group variable (test interval: base-

line, Pre-HA and Post-HA and Post one year), and

interaction effects. Significant effects were examined

with Bonferroni-corrected post hoc t-tests.

Results

Table I shows mean scores and standard deviations

for the questionnaires measured at the test intervals

Baseline, pre-fitting (Pre-HA), post hearing aid fitting

(Post-HA), and at the one-year follow-up (Post one

year). Also shown in Table I are the F-values for

Sound awareness pre-fitting intervention 133

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Table I. Mean and standard deviations (SD) for measurements at baseline, pre-hearing aid fitting (Pre-HA), Post-hearing aid fitting (Post-

HA), and for one-year follow-up (Post one year). Also shown are F-values from baseline to Pre-HA (1�2), baseline to Post-HA (1�3), and

from Post-HA to Post one year (3�4) for between-group effects (B) F(1,35), within-group effects (W) and interactions (I) F(2,70).

Treatment Control

Mean SD Mean SD F-Value 1�2 F-Value 1�3 F-Value 3�4

HHIE

HHIE tot

Baseline 40.2 12.0 42.6 14.9

Pre HA 29.7 13.2 37.8 16.8 W:10.96** W:172.72*** W: 25.34***

Post HA 9.9 7.0 10.1 8.3

Post 1 year 22.1 17.1 18.2 9.6

HHIE S

Baseline 20.4 5.3 22.0 6.4

Pre HA 14.6 6.9 18.8 7.1 W:23.83** W:214.37*** W: 25.62***

Post HA 5.7 3.6 5.3 3.8

Post 1 year 11.5 9.2 10.3 5.0

HHIE E

Baseline 19.8 8.6 20.6 9.2

Pre HA 15.1 8.9 18.9 10.2 W:4.16* W:110.84*** W: 18.48***

Post HA 4.2 4.8 4.8 5.6

Post 1 year 10.6 8.6 7.9 5.4

ECHO

ECHO tot

Baseline 5.2 0.4 5.1 0.4

Pre HA 5.5 0.4 5.1 0.4

ECHO PI

Baseline 5.1 0.9 5.2 1.0

Pre HA 5.5 1.0 5.1 0.8

ECHO PE

Baseline 5.5 0.5 5.4 0.6

Pre HA 5.7 0.4 5.5 0.7

ECHO SC

Baseline 5.9 0.6 5.5 0.8 B:5.06*

Pre HA 6.1 0.6 5.7 0.8

ECHO NF

Baseline 4.4 1.2 4.8 0.9

Pre HA 4.9 0.8 4.4 1.0 I:5.53*

CSS

CSS M

Baseline 4.0 0.4 3.9 0.5

Pre HA 4.0 0.5 4.0 0.4 W:34.33***

Post HA 4.3 0.5 4.5 0.3

Post 1 year 4.3 0.4 4.4 0.4

CSS V

Baseline 2.9 0.8 2.5 0.6 B: 5:14*

Pre HA 2.9 0.7 2.5 0.6 W:24.41***

Post HA 2.4 0.8 2.0 0.6

Post 1 year 2.5 0.7 2.2 0.8

134 M. Oberg et al.

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repeated measures (ANOVA) showing the between-

group effects (B) (group: treatment vs. control),

the within-group effects (W), and interactions

between groups and test interval (I) for the measure-

ments baseline to Pre-HA (1�2), baseline to Post-

HA (1�3) and Post-HA to Post one year (3�4).

Immediate effects of the pre-fitting intervention: Baseline

to Pre-HA

Overall, there were few indications of any interaction

effects, suggesting that the groups did not differ

depending on whether sound awareness training had

been provided or not. As seen in Table I, between-

group main effects were found for CSS V and for

ECHO SC, but post hoc analysis failed to show any

significant between-group differences after the pre-

fitting. Only one significant interaction effect was

found between group and test interval and this was

for ECHO NF, where the treatment group became

more positive regarding negative features of the

hearing aids, whereas the control group became

more negative and decreased scores during the

waiting time. Significant within-group effects were

found for HADS tot, HADS A, HHIE tot, HHIE S,

and HHIE E, but again no interaction effects.

Baseline to Post-HA

In order to test if there were any transfer effects from

the pre-fitting intervention to the post hearing aid

assessment, we tested the 2�2 interaction between

group and time (pre- to post-fitting). No significant

interaction effects were found regarding main effects

of time and group. All subscales in Table I showed

significant within-group effects (W).

Post-HA to Post one year

Table II shows means and standard deviations for

Post-HA and Post one year for the subscales

evaluated on these two occasions. Also shown are

Table I (Continued)

Treatment Control

Mean SD Mean SD F-Value 1�2 F-Value 1�3 F-Value 3�4

CSS NV

Baseline 3.6 0.7 3.4 0.7

Pre HA 3.6 0.7 3.2 0.8 W:38.86*** W:5.23*

Post HA 3.1 1.0 2.5 0.8

Post 1 year 3.3 0.9 2.8 0.9

HADS

HADS tot

Baseline 9.6 8.0 9.3 6.3

Pre HA 6.8 4.0 7.5 5.7 W:7.82** W:22.63***

Post HA 4.3 3.4 5.4 6.8

Post 1 year 5.4 3.1 5.6 6.5

HADS A

Baseline 5.6 4.4 5.6 4.5

Pre HA 3.9 2.2 4.1 3.8 W:10.93** W:16.29***

Post HA 2.6 2.4 3.5 4.8

Post 1 year 3.1 2.1 3.4 4.6

HADS D

Baseline 4.1 4.2 3.7 2.5

Pre HA 2.9 2.1 3.4 2.6 W:22.09***

Post HA 1.7 1.5 1.8 2.2

Post 1 year 2.2 1.8 2.2 2.6

*pB.05 **pB.01 ***pB.001.

HHIE: Hearing Handicap Inventory for the Elderly; HHIE E and HHIE S measure the Emotional and Social/Situational consequences of

hearing impairment ECHO: Expected Consequences of Hearing aid Ownership, Personal Image (PI), Positive Effects (PE), Service and

Cost (SC), and Negative Features (NF). CSS: Communication Strategies Scale. Maladaptive (M), Verbal (V) and Non-Verbal (NV)

strategies. HADS: Hospital Anxiety and Depression Scale; HADS A: Anxiety and HADS; D: Depression. In the HHIE and the HADS

higher scores indicate more problems and in the ECHO higher scores indicate higher expectations. In the CSS M higher scores indicate less

maladaptive behaviour and in CSS V and NV higher scores indicate more frequent use of strategies.

Sound awareness pre-fitting intervention 135

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the F-values for between-groups (B), within-group

(W) effects and interaction effects (I).

As a way to investigate long-term transfer effects of

the pre-fitting sound awareness training we analysed

the results from Post-HA to one-year follow-up,

again with treatment group as one factor and time as

within-group factor. Overall, no effects of the pre-

fitting intervention could be found. One interaction

effect was, however, found for IOI-HA item 1

F(1,32)�5.03, p�.031) showing a larger deteriora-

tion for hearing aid use in the treatment group.

Significant within-group effects were found for

several subscales (see Tables I and II), indicating

deterioration over time.

Clinical assessment at one-year follow-up

The clinical assessment of the users into categories

showed no difference in number of successful/less

successful users between groups and showed that the

majority of the users were classified as successful

users, regardless of pre-intervention training (Figure

2). Four users were assessed as successful with

limitations, and these were equally divided between

groups. Only one user was rated as unsuccessful.

The assessment made by the audiologist who met

the user and the assessment by the independent

audiologist who performed the telephone interview

were compared. Inter-observer reliability was high

showing identical ratings regarding 88% of the users.

Discussion

The aim of this study was to investigate the

immediate and long-term effects of a pre-hearing

aid fitting intervention. Overall, the pre-fitting sound

awareness training failed to show any benefits over

and above the effects of hearing aid fitting. More-

over, very few effects were found immediately after

the pre-fitting. Two immediate between-group ef-

fects were however observed, but failed to reach

statistical significance in the post hoc analysis. One

significant interaction was found showing that

the treatment group became more positive for

negative features of the hearing aids. After hearing

aid fitting, only within-group effects were found

showing reliable improvements for both groups. No

between-group effects were found Post one year and

only one interaction effect suggesting that treatment

group had decreased their daily use of hearing aid

more than the control group. However, significant

within-group effects showed deterioration over the

long term for most items/subscales (e.g. between

Post- HA and Post one year).

One explanation for the increased scores of

expectations of negative feature (ECHO NF) (which

means a more positive attitude to negative features)

for the treatment group after the pre-fitting might be

due to the increased knowledge about hearing and

hearing aids when being activated in the pre-fitting

intervention, in accordance with the findings of

Eriksson-Mangold et al. (10). The increased scores

might be due to positive experiences of amplified

sounds and the training might also have increased

the users’ positive attitudes related to the importance

of hearing sounds. The control group decreased

their scores of negative feature during the waiting

time. The users in the control group might have

acquired knowledge during the waiting period

through conversations with others telling them

negative opinions about hearing aids.

Large improvements were seen after the conven-

tional hearing aid fitting for participation restriction

(i.e. HHIE), irrespective of group. This is in

accordance with other studies where outcome has

been assessed in a research settings (31,32,33,34,

35,36,37). The increased psychosocial well-being

post hearing aid rehabilitation (i.e. HADS), has

also been shown in previous studies (34,38,39,40).

The fact that improvements were found on both the

HADS and the HHIE (see Table I) is not surprising

as these two measures are correlated, as found in an

earlier study by Oberg et al. (22). Thus, with

reference to the large effect on HHIE and HADS,

it is highly likely that participants improved after

their hearing aid fitting. The pre-fitting intervention

did not seem to add much to this. Even if improve-

ments started earlier during the pre-fitting phase for

the treatment group it is possible that the same

additional effects could be obtained just with con-

ventional hearing aid fitting.

Data on one-year follow-up failed to confirm any

transfer effects of the sound awareness training.

Overall, assessments performed at least six to eight

weeks after hearing aid fitting tend to be stable over

time (3,31,34,41). In contrast, several of the sub-

scales in this study indicated deterioration over a

year. It is difficult to interpret what that represents,

but it could be due to increased social activities after

rehabilitation and possibly experiences of hearing

aids not being as good as expected in some contexts

(32). The clinical assessment in the telephone inter-

view showed mostly well-functioning hearing aid

users and no differences between the groups in the

number of successful/unsuccessful users were found.

Since practically no effects of the pre-fitting inter-

vention were found in the self-report measures, we

have no reasons to believe that the lack of effects in

the interview measure was due to insensitivity of that

measure. In a validation study we found high inter-

observer reliability of the interview (Oberg et al.,

unpublished observation). In outcome research it is

136 M. Oberg et al.

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Table II. Mean and standard deviations (SD) for measurement post hearing aid fitting (Post-HA), and for one-year follow-up (Post one

year). Also shown are F-values from Post-HA to Post one year (3�4) for between-groups effects (B) F(1,35), Within-group effects (W), and

interactions (I) F(2,70).

Treatment Control

Mean SD Mean SD F-value 3�4

SADL

SADLtot

Post HA 5.8 0.3 5.7 0.5 W: 15.27***

Post 1 year 5.6 0.5 5.4 0.5

SADL PI

Post HA 6.2 0.7 6.1 0.6 W: 4.54*

Post 1 year 6.0 0.9 5.8 0.8

SADL PE

Post HA 5.9 0.5 5.6 0.7 W: 6.31*

Post 1 year 5.8 0.7 5.4 1.0

SADL SC

Post HA 6.5 0.5 6.3 0.6 n.s

Post 1 year 6.3 0.6 6.2 0.6

SADL NF

Post HA 5.4 0.7 5.8 0.7 W: 6.60*

Post 1 year 5.0 1.1 5.4 1.1

IOI-HA

Item 1

Post HA 4.2 0.6 4.1 0.9 W: 17.08**

Post 1 year 3.7 0.9 4.0 1.0 I:5.03*

Item 2

Post HA 4.5 0.6 4.4 0.7 W: 7.04*

Post 1 year 4.4 0.5 4.1 0.6

Item 3

Post HA 4.2 0.5 4.2 0.7 W: 20.76***

Post 1 year 3.6 0.8 3.7 1.0

Item 4

Post HA 5.0 0 4.8 0.4 W: 14.52***

Post 1 year 4.6 0.5 4.6 0.6

Item 5

Post HA 4.8 0.4 4.7 0.6 W: 4.68*

Post 1 year 4.6 0.6 4.4 0.7

Item 6

Post HA 4.6 0.6 4.5 0.6 W: 4.18*

Post 1 year 4.3 0.7 4.2 0.9

Item 7

Post HA 4.2 0.7 4.2 0.8 W: 7.67**

Post 1 year 4.2 0.8 3.6 1.0

*pB.05 **pB.01 ***pB.001.

SADL: Satisfaction with Amplification in Daily Life, Personal Image (PI), Positive Effects (PE), Service and Cost (SC), and Negative

Features (NF). IOI-HA: International Outcome Inventory for Hearing Aids. Item 1: use; item 2: benefit; item 3: residual activity limitation;

item 4: satisfaction; item 5: residual participation restriction; item 6: impact of others; item 7: quality of life. Higher scores indicate less

problems.

Sound awareness pre-fitting intervention 137

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often recommended to complement self-report mea-

sures with evaluations in structured interviews, but to

our knowledge this has rarely been done in audio-

logical rehabilitation research.

Possible explanations and limitations

This pre-fitting approach, with the purpose to

facilitate acclimatization to sounds, did not result

in any additional effect in the long term. These

findings are in line with Norman et al. (5), who also

failed to find any effects on measures of outcome of

hearing aid fitting after a pre-fitting intervention.

It is possible that users’ degree of hearing loss was

too mild and that initial scores for activity limitation

and participation restriction were in the lower range.

Kemker and Holmes (6) reported that only those with

greater initial scores on activity limitation received

significantly greater satisfaction from pre-fitting and

post-fitting counselling. Another aspect is that the

questionnaires used in this study may not be sensitive

enough to measure differences between interven-

tions, and/or that the study may have been under-

powered with respect to number of participants.

When designing the study it was difficult to actually

set up a possible expected difference between the test

group and control group for the different question-

naires, but in retrospect it seems that the groups were

somewhat too small to establish statistically signifi-

cant differences between the groups.

It could also be argued that the sound awareness

training could have been made more appropriate.

The users were recommended to gradually increase

the difficulty of the listening environments (i.e. from

more or less silent to increasingly complex sound

environments). A gradual increased amplification

could also have been relevant. Barfod (42) claimed

that the immediate change of input of sounds that

hearing aid amplification provides, causes a mis-

match in the speech perception processing which

could be interpreted as a negative experience of

intelligibility of the user. A gradually increased

amplification and a longer period of sound aware-

ness training might have increased the effects of the

intervention. On the other hand, studies of a later

date have shown higher rates of change on self-

report questionnaires, when assessments have been

conducted three weeks after fitting, compared to

assessments carried out three months post hearing

aid fitting. This suggests that amplification can

indeed be beneficial also in the short term (32,35).

In this study the conventional hearing aid fitting

procedure in itself appeared to be effective in terms

of reducing self-reported activity limitation and

participation restriction. Perhaps little room was

left for finding any transfer effects from the pre-

fitting intervention following the fitting. In our

previous study on pre-fitting we found somewhat

better immediate effects, but in line with the present

study there were no clear transfer effects once the

hearing aids had been fitted (Oberg et al., unpub-

lished observation). Brooks (4) did find differences

between groups in his study on pre-fitting, but in

contrast to the present study, the control group of

Brooks only had one visit.

Finally, one interpretation of the results is that we

devoted too much time on the control participants

and that filling out questionnaires, including the use

of the COSI questionnaire, might be therapeutic in

itself (43,44,45). It has been stated that the COSI

0

2

4

6

8

10

12

14

16

1=Successful 2=Successful withlimitations

3=Unsuccessful

Categories

Nu

mb

er o

f su

bje

cts

SA

CTRL

Figure 2. Distribution of the categories (1) successful, (2) successful with limitations, and (3) unsuccessful audiological rehabilitation for

treatment (SA) and control (CTRL) group.

138 M. Oberg et al.

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has the potential to positively affect the rehabilitation

process and the use of this instrument in the present

study may have boosted the effects of the hearing aid

fitting (23). Dillon (3) stated that the only counsel-

ling that should be performed prior the individual

hearing aid fitting is counselling related to attitudes,

motivation and to the choice of hearing aids. In this

study the users were recruited consecutively from the

waiting list and no special attention was paid to

evaluate the user’s attitudes and motivation. Poten-

tially, results would have been different if only users

with low motivation and negative attitudes towards

hearing aids had been included.

Conclusions

The aim of the study was to investigate the immediate

and the long-term effects of a sound awareness pre-

fitting intervention. The small benefits found, if any,

do not support the use of pre-fitting sound awareness

training. No clear immediate effects or transfer effects

following hearing aid fitting could be established, but

within-group effects suggests that hearing fitting per

se has an effect on activity limitation, participation

restriction and psychosocial well-being. Future re-

search should target individuals in need of pre-fitting.

Acknowledgements

This study was supported by grants from the Oticon

Foundation, Oticon A/S, and from the Swedish

Hard of Hearing Association (HRF). We would

like to thank all subjects who participated. We are

also grateful to Helen Hjertman for administration

of the one-year follow-up.

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