or condition based solely on the opinion of the examiner or client. For example, a client may report that he experiences severe tinnitus, yet the tinnitus is not audible to the audiologist. The term self-assessment reflects a client’s own self-evaluation of his/her perceptions and performance. This is a reflective process in which the individual considers his/her own strengths, weakness, and overall performance (Harvey, 2004). This type of measure can be administered after a treatment as an outcome assessment, before a treatment to develop rehabilitation goals, or during a treatment to monitor treatment progress. The term self-assessment will be used throughout the remainder of this chapter as it best reflects the diversity of clinical application.
Why Is Self-Assessment Important?
The routine use of self-assessment as part of comprehensive audiologic rehabilitation (AR) is a philosophically based decision. From the client’s perspective, AR should not be an afterthought to a diagnostic evaluation, but rather in keeping with the primary purpose of the client seeking our services. A client does not come to the audiologist because of a hearing loss, but rather because he/she is experiencing communication difficulties. The remediation of those difficulties clearly goes beyond simply measuring an audiogram. Planning for AR services begins the moment the client walks through the door. Client-centered care necessitates that the individual’s experiences be part of that process. Self-assessment is a quick and easy way to document these client needs and expectations.
Self-assessment measures can be used in a variety of ways. Table 6–1 includes applications for both disease-specific and generic self-assessment measures. Disease-specific assessments evaluate a particular disease or condition. For example, the Abbreviated Profile of Hearing Aid Benefit (APHAB) can be used to evaluate auditory disability before and after the provision of hearing aids (Cox & Alexander, 1995). The Hearing Handicap Inventory for the Elderly (HHIE) can be used to assess a client’s perceived handicap as a result of hearing loss (Ventry & Weinstein, 1982). Disease-specific instruments have been shown to be sensitive to pre- versus post-treatment measures in audiology (Abrams & Chisolm, 2014). Generic measures, in contrast, allow for comparisons to be made across diseases or conditions. General QoL measures fall into this latter category. Saunders and colleagues (2005) noted that generic measures afford audiologists several advantages over disease-specific measures, including the consideration of hearing rehabilitation in a broader health care context; the application of cost-benefit analysis; which may affect resource allocation; a better understanding of underlying issues that may affect rehabilitation efforts; and, finally, a comparison across sensory or rehabilitation aids, as is the case when a client wears both hearing aids and eyeglasses.
An Opportunity to Remain Client-Focused
Clinicians may argue that self-assessments are not needed: “I can find out my client’s needs with a thorough case history” or “I can simply ask how my client is doing.” For many years this was the reason given for clinicians’ failure to adopt the use of self-assessment tools (Nemes, 2003). Fortunately, clinicians are recognizing the need for formal verification of benefit and satisfaction using a self-assessment tool, at least when dispensing hearing aids. In The Hearing Review Dispenser Survey of 2002 (Strom, 2002), only 19% of the more than 600 respondents reported administering a self-assessment tool for hearing aid clients “always or nearly always.” Nearly half of the sample (43%) reported at that time that they “seldom or never” used such measures. In The Hearing Review Dispenser Survey of 2006 (Strom, 2006), 77% of dispensing audiologists and 76% of hearing instrument specialists reported using self-assessment tools. Most hearing instrument specialists reported that a survey developed in their own office was the instrument of choice, while more than half of dispensing audiologists reported using a published survey such as the Client Oriented Scale of Improvement (COSI) (Dillion et al., 1997) or the APHAB (Cox & Alexander, 1995). This represents a substantial increase in the reported usage of self-assessment tools. Although it is unclear how audiologists incorporate this information into their clinical practice (Erdman, 1993, 2009) with recent survey data suggesting that many audiologists are using the information to validate treatment outcomes (ASHA, 2012).
It is important to note that self-assessment is a multidimensional process. The psychosocial impact of hearing loss and communication difficulties cannot be easily predicted from the audiogram or other diagnostic measures (Newman et al., 1990; Saunders & Cienkowski, 1996; Weinstein & Ventry, 1983). Furthermore, help-seeking behaviors are more strongly correlated with self-reported hearing loss than with audiometric thresholds (Duijvestijn et al., 2003; Laplante-Lévesque, Hickson, & Worrall, 2011a; Swan & Gatehouse, 1990). It is imperative to use a formal assessment because clinician impressions and client impressions may not always be in agreement. A clinician’s initial impressions of a client’s communication problems or needs may artificially constrain future assessments and influence outcomes (Schneider et al., 2005). Social psychologists refer to this as an anchoring effect when a clinician’s first impression may bias future interactions and interpretations (Leary & Miller, 1986). When new or different information comes to light, it may be difficult for the clinician to change course or revise a rehabilitation plan (Friedlander & Stockman, 1983). See an example of this in the case study below.
Case Study 6–1. Mrs. X., the Finicky Hearing Aid User
Mrs. X. was a 75-year-old woman with a long-standing sensorineural hearing loss. Her hearing loss was identified at age 50 and she has worn four sets of hearing aids since that time. She has a family history of hearing loss as well as a history of noise exposure. She was an accomplished violinist and actively plays in a community orchestra. Her general health was good, with the exception of high blood pressure, which was controlled by prescription medication. She was widowed and lived alone in a single-family home. She had two adult children who resided in neighboring towns and one granddaughter away at college. Her most recent audiologic evaluation revealed a stable, moderately severe to severe sensorineural hearing loss bilaterally. Word recognition was fair in both ears when recorded monosyllabic words were presented at elevated conversational levels. Tympanometry revealed Type A tympanograms bilaterally with absent ipsilateral acoustic reflexes. Otoscopic results were unremarkable and ear canals were clear bilaterally. Mrs. X.’s current hearing aids were approximately 7 years old. Electroacoustic evaluation found the aids to be weak when compared to manufacturer specifications and it was recommended that Mrs. X. purchase a new set of hearing aids rather than repair her current aids, given the age of the devices and the outdated technology. Mrs. X. agreed. The clinician selected and ordered new receiver in the canal hearing aids with micromolds, took ear impressions for the micromolds, and scheduled a follow-up appointment.
Mrs. X. returned to the clinic to pick up her new hearing aids. The audiologist programmed the aids with three stored functions. The first program was “listening in quiet” with prescriptive gain set to match a standard NAL-NL2 target. The second program was “listening in noise.” Based on the prescribed gain from the first program, the second program also incorporated adaptive directionality and multiband noise reduction. The third program was set for telephone use with auto telecoil activated. The audiologist confirmed a match of the first program to the prescriptive gain target within 4 dB using real ear measures. The micromolds were modified slightly for comfort. Mrs. X was counseled on the care and use of her new devices and advised that she had a 30-day trial period with the new aids. She signed up for a 3-week “Living With Hearing Loss” class.
A few days later Mrs. X. returned to the clinic. “Something is wrong with these new hearing aids,” she stated. “They are not loud enough.” The audiologist confirmed by electroacoustic evaluation that the aids were in working order. She reprogrammed the aids, increasing the gain by 5 dB. Mrs. X. reported the aids “do sound louder” and continued with her trial period. She returned two additional times during the first week to have the aids tweaked. “I think my old aids sounded better,” she stated. The following week the “Living With Hearing Loss” class began. Mrs. X. was excited. Although she was an experienced hearing aid user, she was not happy with her new devices and felt there was a lot she could still learn about managing her hearing loss. As part of the class, each participant was asked to complete a COSI and a HHIE. Ranked from most important to least important on the COSI, Mrs. X. identified listening to music, conversations with her children on the phone, and watching television as the three areas in which she would like to receive benefit from her hearing aids. She scored a 36 overall on the HHIE, indicating that she experienced a moderate hearing handicap, even while wearing her hearing aids. Realizing that her trial period was nearly finished, Mrs. X. returned to the clinic to return her hearing aids. After receiving the self-assessments, the audiologist reassessed Mrs. X.’s fitting. It was clear from the information Mrs. X. provided that her new fitting was not satisfactory. It was also apparent that listening to music was the situation that Mrs. X. felt was most important. Although her new aids provided adequate audibility for everyday listening, the aids were not ideal for nonspeech stimuli. The audiologist returned the aids and ordered a different pair that was known to provide a wider dynamic range for input signals. Mrs. X. returned to the clinic and was fit with the new aids. Two weeks into her new trial period Mrs. X. reported much improved sound quality when listening to music. On a HHIE administered 1 month post-fitting, Mrs. X. scored a 10, indicating a significant reduction in her hearing handicap. Consider how the use of self-assessment altered the outcome of this routine hearing aid fitting. How might self-assessment be integrated into the clinical process earlier to facilitate the aural rehabilitation?
Incorporating Self-Assessment Into Clinical Practice
Clinicians may be overwhelmed by the number of self-assessment tools at their disposal. There is a plethora of instruments currently available to practitioners. The selection of a self-assessment tool begins with the identification of the underlying theoretical framework for the assessment to determine what question(s) the clinician wants to ask. All self-assessments are inherently designed to provide the clinician and the client with feedback on the AR process. But it is important that reflection or self-assessment results in action. A framework is a way of linking the goals of AR with change and the activities leading to perceived change and sustainable development (Lusthaus et al., 2002). The World Health Organization’s International Classification of Functioning, Disability, and Health (WHO-ICF) (World Health Organization, 2001) outlines a conceptual classification system that describes the consequences of health conditions, including hearing loss, and has been applied to AR (Bruyère et al., 2005; Gagné et al., 2014). Within this model, sensorineural hearing loss may be viewed as a chronic health condition and, although treatment plans may result in successful management of the communication difficulties associated with this loss, the hearing loss itself remains unchanged (Gagné et al., 2014). Notably, the ICF also takes into account individual factors such as personality, culture, social situation, and environmental factors that are critical components in the management of hearing loss.
Gagné and colleagues (Gagné et al., 2014; Gagné & Jennings, 2008) advocate the use of the ICF (Figure 6–1) as a conceptual framework. They note that, within that framework, AR is defined as an intervention procedure that attempts to restore participation in activities that was limited or restricted by the hearing loss. This functional description of difficulties may affect both the individual with hearing loss and his/her significant others or communication partners. Clients are directed to describe their communication problems in a context that is meaningful to them. This, in turn, will direct the AR in a way that is relevant to the client’s everyday life. For example, instead of the clinician asking the client, “Do you have difficulty hearing in noisy places?” through self-assessment the client might state, “I have difficulty hearing my wife and children when we go to Sunday brunch at a restaurant.” The latter example provides a specific goal to be addressed and assessed post-intervention. With this in mind, the following section describes specific questions or areas that audiologists may wish to assess in daily practice. Table 6–2 provides an overview of these areas, along with examples of self-assessment tools that might be beneficial in addressing these topics. Again, these are examples only. There are many self-assessment tools that address each of these areas.
Figure 6–1. Model of disability and function for hearing loss based on World Health Organization’s International Classification of Functioning, Disability, and Health (WHO-ICF, 2001).
Identifying and Prioritizing Problems
One challenge in the management of hearing loss is that hearing loss affects individuals in different ways. Reduced audibility results in diminished access to auditory information (Humes & Dubno, 2010; Van-Tasell, 1993). This is factored into threshold-based prescriptive fitting of amplification devices (Dillon, 2012). For the use of devices to be successful, however, the clinician must also consider the nature of the input signal to the device; that is, the speech or nonspeech signal and the environmental conditions in which the signal is heard. Environmental factors such as distance, noise, and reverberation should be considered (Van Tasell, 1993). Furthermore, the amplification device needs to provide benefit in those situations in which the client is having difficulties. For example, a directional microphone can improve signal-to-noise ratio, but is only effective in the near field or close distance (Dillon, 2012). If a client’s complaint is listening to a lecture in background noise when seated at the rear of an auditorium, a directional microphone will provide limited benefit. Management of this communication difficulty may be better addressed with preferential seating or hearing-assistive technology. A self-assessment tool can be useful to identify those situations in which the client is experiencing difficulties. For example, the Hearing Performance Inventory (HPI) developed by Giolas and colleagues (1979) examines client performance in everyday listening situations. The inventory looks at speech understanding, social communication, personal communication, work communication, and reactions to unsuccessful communication (Bentler & Kramer, 2000). The original version contains 158 items and takes approximately 30 to 40 minutes to administer. The revised version contains 90 items (Lamb, Owens, & Schubert, 1983) and takes approximately 20 minutes to administer if occupational items are omitted (Huch & Hosford-Dunn, 2000). The Communication Profile for the Hearing Impaired (CPHI) (Demorest & Erdman, 1987) is another example of a comprehensive tool that assesses communication problems in a variety of situations. Areas addressed in the 145-item questionnaire include communication performance, communication environment, communication strategies, personal adjustment, and denial. The CPHI incorporates evaluation of activity limitations, participation restrictions, and environmental factors; as such, it is a comprehensive tool. The drawback to the CPHI, similar to that of the HPI, is that it takes approximately 30 to 40 minutes to administer (McCarthy & Alpiner, 2000). As an alternative, the Screening Test for Hearing Problems (STHP), developed by Demorest, Wark, and Erdman (2011), is based on items from the CPHI but includes only 20 items, and thus is more time efficient. The COSI (Dillon, James, & Ginis, 1997), in contrast, is an open-ended self-assessment tool. The client can identify up to five situations in which communication or listening is a problem and prioritize them, after consultation with the audiologist. The client rates those situations with regard to the degree of change provided by the amplification device and also rates his/her final ability with the device. The COSI is highly individualized and easily incorporated into the rehabilitation plan. The drawback is that clients may find it difficult to identify specific situations and prioritize them easily.
Facilitating Communication
Good rapport between the client and clinician is critical for successful rehabilitation. Each individual is unique and has his/her own individual characteristics, so there is no one assured way to establish rapport. The ability to make a connection with the client may influence future interactions and rehabilitation outcomes (Thomas & Hersen, 2009). It has been shown that client-centered communication is significantly correlated with a person’s willingness to disclose information. Clinician interaction styles that are focused on client’s needs or concerns result in more effective communication between the clinician and client (Berrios-Rivera et al., 2006). Without trust between the client and clinician, a barrier is erected that may reduce adherence to the rehabilitation plan and limit positive health care outcomes.
Table 6–2. Incorporating Self-Assessment Into Clinical Practice
Source: Adapted from Higginson & Carr, 2009.
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