Keywords
hearing aids - public health - patient compliance
Introduction
According to hearing aid fitting guidelines,[1]
[2]
[3] rehabilitation with hearing aids should maximize residual hearing of subjects over
time, including characteristics of hearing loss, individual profile, and personal
needs. To keep fittings up-to-date, periodic interventions might be necessary to solve
problems that may occur over time, such as broken earmolds or changes in hearing.[4]
[5] Therefore, follow-up appointments are essential to guarantee long-term effectiveness
of treatment.[2]
[3]
[5]
[6]
[7]
Patient adherence in long-term treatment for chronic conditions may also influence
outcomes and effectiveness of interventions. The term adherence refers to the degree a subject's behavior corresponds to and agrees with the prescriptions
and recommendations of the proposed treatment, and adherence may be influenced by
factors related to the disease itself, the treatment process, the health care provider,
and social and economic aspects, among others.[8]
[9]
[10]
[11]
[12] Poor adherence results in poor health outcomes, limited control of the disease,
waste, and underutilization of treatment resources.[10]
Hearing aid use can reflect the effectiveness of hearing rehabilitation.[13] Users tend to abandon hearing aid use over time, mainly because of fitting problems.[4]
[5]
[14]
[15]
[16] On the other hand, not all users adhere to the treatment's prescriptions, and some
do not attend follow-up appointments, which may directly affect long-term effectiveness
and nonuse of hearing aids.
The purpose of the present study was to compare hearing aid use between subjects who
did not attend a follow-up evaluation appointment at a publicly-funded health service
(nonattenders) and those who attended an appointment (attenders). Reasons for nonuse
of hearing aids and unscheduled appointments were also analyzed.
Methods
This cross-sectional survey was approved by protocol number 0160/10 by the ethics
committee on research. In all, 376 users whose hearing aids dispensed and fitted 1 year
previously in a publicly-funded health service from the city of São Paulo, Brazil,
were selected from medical records and invited to participate in this study via telephone
interview. Considering one of the purposes of this study was to identify factors that
lead to hearing aid nonuse and use/fitting problems that may occur over time, we sought
to select subjects who did not have other issues that could affect hearing aid use
and maintenance, such as chronic middle ear infection or fluctuating hearing loss.
Inclusion criteria were: adults (at least 18 years old) diagnosed with mild to moderately
severe, bilateral and symmetric sensorineural hearing loss, who wore digital behind-the-ear
hearing aids with nonlinear amplification in both ears for 1 year, with no previous
experience with hearing aids. Subjects with neurologic disorders, outer or middle
ear malformations, manual dexterity problems, or fluctuating hearing loss were excluded.
Procedures
Active Search by Telephone
All 376 subjects were invited by telephone to attend a follow-up evaluation of hearing
aid use in the same institution that fitted the hearing aids for them, as described
by Iwahashi et al.[5] Up to five phone call attempts in three different times of the day were made, and
subjects were considered unreachable by telephone if the phone number was incorrect
or none of phone call attempts were answered.
When a phone call was successfully made, subjects were offered three different options
to schedule an appointment for the follow-up evaluation. To reduce the number of nonattenders,
subjects were called the day before the scheduled appointment as a reminder or to
reschedule a new appointment if necessary. Subjects who did not schedule an appointment
were asked about the reason for not attending the publicly-funded health service.
Interview
Users, respective caretakers, or users' acquaintances were interviewed by telephone
after stating they authorized the use of collected data in this study. The audiologist
responsible for the research conducted all the interviews, as a previous step to the
follow-up evaluation described in Iwahashi et al,[5] to consider the probable bias for subjects who would not attend the appointments.
The interview consisted of the following questions: (1) Have you been wearing your
hearing aids? (2) Do you usually wear both hearing aids (bilateral), only one hearing
aid (unilateral), or none of them? If the subject wore none or only one of the hearing
aids (unilateral), a third question was asked: (3) What is the main reason for not
wearing your hearing aids?
Data Analysis
Subjects were divided in two groups according to attendance at the follow-up appointment.
The nonattenders group comprised all subjects who were absent from or did not schedule
a follow-up appointment, and the attenders group contained all subjects who attended
the follow-up evaluation appointment.
Data were analyzed with descriptive statistics and logistic regression analysis.[17]
Results
Active search resulted in 308 users interviewed by telephone, or 81.91% of the initial
sample ([Fig. 1]). The nonattenders group consisted of 108 subjects; 63 (58%) were women and 45 were
men (41%), and their ages ranged from 21 to 94 years (mean 69.71, standard deviation
[SD] ± 15 years). The attenders group consisted of 200 subjects, of whom 102 were
women (51%) and 98 were men (48%), with ages ranging from 26 to 101 years (mean 71.33
years, SD ± 11 years). In both groups, most subjects did not have more than 4 years
of formal education and were not economically active.
Fig. 1 Outcomes of active search by telephone.
Most subjects in both groups maintained bilateral use of hearing aids after 1 year,
but nonuse was greater in the nonattenders group ([Fig. 2]). Inferential analysis by logistic regression showed that being from the attenders
group was statistically different from nonattenders group, adjusting for gender, degree
of hearing loss, and age; in other words, only attendance was associated with hearing
aid use ([Table 1]). Logistical regression analysis also showed that the probability of abandoning
hearing aid use was significantly higher in the nonattenders group; there was no intersection
between the confidence intervals, and abandoning use was more than twice as likely
as that for the attenders group ([Table 2]).
Table 1
Model of logistic regression for estimate of hearing aid nonuse according to age,
degree of hearing loss, gender, and group
|
Variable
|
Estimate
|
Standard error
|
p Value (α= 0.05)
|
|
Constant
|
−0.72
|
0.38
|
0.058
|
|
Age
|
0.02
|
0.01
|
0.191
|
|
Degree of hearing loss (moderate)
|
0.03
|
0.37
|
0.928
|
|
Degree of hearing loss (moderately severe)
|
0.32
|
0.47
|
0.502
|
|
Gender (male)
|
−0.48
|
0.31
|
0.116
|
|
Group (attenders group)
|
−1.04
|
0.30
|
<0.01
|
Table 2
Model of logistic regression for estimate of hearing aid nonuse in nonattenders and
attenders groups
|
Estimate (%)
|
95% confidence interval
|
p Value (α= 0.05)
|
|
Nonattenders group
|
30.6
|
22.6–39.9
|
<0.01
|
|
Attenders group
|
13.0
|
9.0–18.4
|
<0.01
|
Fig. 2 Hearing aid use according to attendance in follow-up appointment.
Stated reasons for nonuse of hearing aids differed between both groups. Health problems
were an important issue for nonuse in the nonattenders group; fitting problem was
the main reason in the attenders group ([Table 3] and [Table 4]).
Table 3
Reasons for nonuse of hearing aids in nonattenders group
|
Reason
|
n
|
%
|
|
Health problems
|
11
|
28.9
|
|
Poor sound quality
|
5
|
13.2
|
|
Poor benefit
|
5
|
13.2
|
|
Faulty hearing aid
|
2
|
5.3
|
|
No need of hearing aids
|
1
|
2.6
|
|
Could not state the reason
|
14
|
36.8
|
|
Total
|
38
|
100.0
|
Table 4
Reasons for nonuse of hearing aids in attenders group
|
Reason
|
n
|
%
|
|
Poor sound quality
|
14
|
29.8
|
|
Poor benefit
|
8
|
17.0
|
|
Manual dexterity issues
|
7
|
14.9
|
|
Faulty hearing aid
|
7
|
14.9
|
|
Fit discomfort
|
5
|
10.6
|
|
Health problems
|
4
|
8.5
|
|
Lost hearing aid
|
2
|
4.3
|
|
Total
|
47
|
100.0
|
The main reasons indicated for unscheduled follow-up appointments in the nonattenders
group were health problems and unavailable companion ([Table 5]).
Table 5
Reasons for unscheduled follow-up appointments by subjects of nonattenders group
|
Reason
|
n
|
%
|
|
Health problems
|
22
|
32.4
|
|
Unavailable companion
|
21
|
30.9
|
|
Unavailable to schedule appointment
|
11
|
16.2
|
|
Transportation difficulties
|
8
|
11.8
|
|
Returned hearing aid
|
6
|
8.8
|
|
Total
|
68
|
100.0
|
Discussion
Studies about effectiveness of hearing health care provided by publicly-funded services
are important to improve treatment quality and optimize the utilization of public
resources.[5]
[18]
[19] However, effectiveness is not only affected by lack of quality in treatment or limited
resources, and this study took a different approach, evaluating how treatment adherence
could affect outcomes in rehabilitation with hearing aids in a publicly-funded service
located in the city of São Paulo, Brazil.
Hearing Aid Use and Attendance in Follow-Up Appointments
Among possible factors related to hearing aid use evaluated in [Table 1], only attendance to follow-up appointment was statistically significant to use between
age, gender, or degree of hearing loss. This differs from results seen in Swiss population
in a study by Bertoli et al,[20] where age, gender, and degree of hearing loss were statistically significant to
use but agrees with results by Lupsakko et al[21] and Jerram and Purdy.[22]
As seen in [Fig. 2], most users kept bilateral use of hearing aids after a year, and the nonuse rate
in the nonattenders group was more than twice that in the attenders group. Estimates
in [Table 2] also revealed that treatment was less effective in nonattenders of follow-up appointments,
considering the significantly greater probability of abandoning hearing aid use. In
short, nonattenders were more likely to become nonusers of hearing aids, or from a
different perspective, treatment effectiveness tended to be weaker in nonadherent
users.
Even with actions to improve the coverage and quality of rehabilitation with hearing
aids, it is essential that subjects follow the recommended prescriptions in treatment
for its adequate execution by the publicly-funded health services, otherwise all the
efforts will lead to insufficient treatment success and outcomes.[10] The nonattenders group consisted of 35% of participants; changes in the follow-up
system are required to raise attendance and adherence after the fitting process for
better use of hearing aids over time and optimization of public resources.
Reasons for Nonuse of Hearing Aids
As seen in [Tables 2] and [3], reasons for nonuse of hearing aids differed in both groups. In the nonattenders
group, 36.84% subjects could not state reasons for nonuse reasons, which was not seen
in attenders group and which may indicate subjects less interested in treatment; 28.95%
reported health problems as major reasons, and the remaining 34.21% had hearing aid
fitting issues. In the attenders group, only 8.51% stated health problems as a reason
for nonuse; most nonusers had hearing aid fitting issues.
In both groups, the majority of subjects evaluated were more than 65 years old, a
portion of the population more often affected by chronic and disabling diseases, which
may lead them to remain in bed or be unable to wear hearing aids. Health problems
was the most commonly stated reason for nonuse in the nonattenders group and also
the main reason for unscheduled follow-up appointments ([Table 4]), affecting adherence to treatment as a whole. The authors considered as health
problems when users, caretakers, or acquaintances stated an issue caused by health
problems that would affect hearing aid use, which included middle ear infection, ear
eczema, pneumonia, necessity to keep hearing aids in all the time, recovering from
ear surgery, and recovering from cancer treatment. There were times the interviews
were held with users' neighbors or acquaintances, and the subject could not give the
precise information.
The other reasons for nonuse of hearing aids in both groups were fitting problems
or problems caused by doubts regarding maintenance and use, which were also seen in
other studies; these problems can be solved with adjustments and orientations usually
done in follow-up appointments to maintain the long-term effectiveness of rehabilitation
with hearing aids.[4]
[5]
Reasons for Unscheduled Follow-Up Appointments
Excepting returned hearing aids, which was a small percentage of total sample, all
reasons for unscheduled follow-up appointments refer to difficulties to fulfill attendance
and maintenance to treatment adherence.
Health problems affected attendance in appointments and was the most often cited reason
for unscheduled follow-up appointments. Statements included necessity to stay in bed
all the time, treatment of middle ear infection, and physical injury that hampers
locomotion until health service, for example, severe stage of osteoarthritis.
Most users were elderly people who lived far from the health service and needed a
companion to bring and accompany them to appointments, which at times could not happen
mainly due to companion's work activities or also work activities of users, which
is reflected in the unavailability to schedule appointment.
Transportation difficulties were also an important factor to consider, because most
users depended on public transportation and needed to take up to six different buses
to attend appointments, which sometimes is financially expensive and/or physically
demanding to their health conditions.
Measures to ease adherence with treatment recommendations by hearing aid users could
improve the effectiveness of rehabilitation and optimize public resources, perhaps
even more than attempts to improve the quality or coverage of health services, as
suggested by World Health Organization.[10]
Long-term effectiveness of rehabilitation with hearing aids provided by publicly-funded
services needs to be improved, which could be done with implementation of measures
to increase adherence to hearing aid use and to prescribed recommendations, to ensure
quality of treatment and optimization of public resources over time. Distance learning
programs for orientation and counseling of hearing aid use using the Internet, tele-audiology,
videoconference software, or instructional videos could help users to solve problems
that may affect fitting quality, such as adequate insertion of earmolds, maintenance
and cleaning of earmolds and hearing aids, and use of hearing aid drying container.
Health services in Brazil are decentralized; hearing aid follow-up centers could also
be implemented in basic health units according to geographical distribution to decrease
attendance difficulties related by nonattendant users.
