& van Heuvelen, 1996). Involving others in the care and treatment necessitates rethinking the manner in which audiology services are provided.

Traditional medical or biomedical models of treatment imply that the audiologist assess hearing and provide a curative philosophy to the identified loss. Essentially, the treatment decision is provided by the audiologist and the patient is informed of the solution—in most cases, amplification. In some situations, this includes deciding upon the style and model of hearing aids (Erdman, 2014; Erdman, Wark, & Montano, 1994; Montano, 2012). Inclusion of others in this process is limited to informing them of a decision already made. In contrast, service delivery using a rehabilitation or biopsychosocial model implies a shared decision process whereby treatment is recommended after discussion of options and an exploration of the issues related to the life of the person with hearing loss, including the communication partners and the environments in which communication takes place (Erdman, 2014; Erdman et.al., 1994; Montano, 2012). (Editors’ note: For further discussion of the biopsychosocial model, the reader is referred to Chapter 11 of this text.)

Significant Other/Communication Partner

The term significant other (SO) is seen throughout health care literature and used frequently by professionals to represent “an individual who has an important role and influence in the shaping of behavior of another” (Montano & Al Makadma, 2012, p. 47). A significant other can be anyone of importance in a person’s life, but usually refers to a spouse, partner, child, sibling, or close friend. There is an abundance of literature on the impact of hearing loss on the significant other, with that person most often being a spouse. Recently, new research is beginning to surface on the impact of a parent’s hearing loss on their adult children (Heacock, Montano, & Preminger, 2018; Preminger, Montano, & Tjornhoj-Thomsen, 2015) Moreover, hearing loss has an impact well beyond a person’s home environment to other areas where communication takes place, such as work and social settings (Noble & Hétu, 1994). For this reason, the term communication partner (CP) has gained popularity in the audiology literature. Montano and Al Makadma (2012) refer to communication partnerships as the “relationships between individuals and groups involved in activities within a communication environment” (p. 48). With the use of this terminology, a person with hearing loss visiting an audiologist with his/her spouse would engage in communication within the audiology office environment and the communication partners would include the husband/wife and the audiologist. The audiologist is a vital partner to both the patient and the spouse. During this communication exchange, the audiologist has the opportunity to explore both the audiologic and nonaudiologic issues related to the hearing loss and develop a keener awareness of the impact on the communication partner. The term family-centered care has begun to be more commonly used in literature and practice. Evidence has shown that outcomes are improved when family is involved in the rehabilitation process (Rathert, Wyrwick, & Boren, 2013; Singh et al., 2016). (For additional information of family-centered care, the reader is referred to Chapter 16 of this text.)

Impact of Hearing Loss on Communication Partners

Prior to considering the impact of hearing loss on a CP, it is useful to consider terminology. Differing language has been used to describe the experience of having a partner with hearing loss. Stephens and Hétu (1991) used the term secondary handicap, which they described as the adjustments employed by CPs to compensate for the hearing disability. As the World Health Organization (WHO) language regarding functioning and disability has changed, so has the terminology used to describe the experience of the CP (Scarinci, Worrall, & Hickson, 2009b). The impact of dealing with a partner with hearing impairment is now termed third-party disability, which can be described as the activity limitations and participation restrictions that result from a partner’s hearing disability (Scarinci et al., 2009b).

In one of the first studies to consider the impact of hearing impairment on CPs, Hétu, Lalonde, and Getty (1987) developed a questionnaire to measure the awareness of hearing disability and the use of coping strategies by men with noise-induced hearing loss (NIHL) and by their spouses. They noted that the entire family had the responsibility of coping with the hearing disability; however, it was observed that both the PHLs and their spouses did not necessarily develop good coping strategies. In a follow-up study (Hétu, Riverin, Lalande, Getty, & St-Cyr, 1988), the authors noted CPs had unique needs that could be addressed via AR. Later, Hétu and colleagues reported CPs may actually impede this AR process by minimizing the problems caused by the hearing loss (Hétu, Riverin, Getty, Lalande, & St-Cyr, 1990).

The emotional effects are listed in Table 19–1 and have been confirmed by a variety of researchers. These findings are based on qualitative research studies in which the CPs were interviewed and allowed to speak freely about living with a partner with hearing loss. In some studies, the partners are spouses (Hétu et al., 1993; Scarinci, Worrall, & Hickson, 2008); in one they were adult children of parents with HL (Preminger et al., 2015), and in two they included family members and friends (Hallam, Ashton, Sherbourne, & Gailey, 2008; Manchaiah & Stephens, 2013). The emotional effects are numerous and include reports of feeling frustrated, irritated, angry, and resentful. As a result, many CPs also feel guilt for having negative emotions, for being impatient with their spouse, or for employing negative communication strategies such as yelling (Hétu et al., 1993; Preminger et al., 2015). CPs may also feel sympathy for their spouses due to the need to cope with the hearing loss and subsequent communication difficulties (Scarinci et al., 2008). Finally, CPs often feel concern for their partner’s safety due to the inability to hear warning signals (Hallam et al., 2008; Preminger et al., 2015; Scarinci et al., 2008). It is interesting to note that the emotion of uncertainty only arose in the study of adult children of parents with HL (Preminger et al., 2015); adult children wondered whether hearing loss or some other factor could explain their deteriorated communication with their parent. In these two examples, one adult daughter wondered if it is hearing loss or a lack of interest in her life that may explain her mother’s communication: “It’s hard to know if she’s just bored and ready to move on to the next thing or, if she really can’t hear what I’m saying.” Another adult daughter wondered if cognitive decline or hearing loss can explain her mother’s communication: “I think the hearing really had become a big problem for her; I was really worried that she was becoming senile and I’m not concerned about that now.”

Some research has specifically focused on positive emotions of CPs. Manchaiah and Stephens (2013) asked CPs to list any positive feelings or events that they experienced due to their partner’s hearing loss. CPs reported increased patience and tolerance, increased awareness and knowledge of hearing loss, reduced stigma related to hearing loss, and improved communication abilities. Heacock, Montano, and Preminger (2018) followed up on this study by asking 48 adult children if they experienced the positive feelings and events described by Manchaiah and Stephens (2013). The most commonly reported experiences were increased understanding and awareness of hearing loss, feeling more helpful or useful, improved communication skills, and increased patience and tolerance related to communication.

Here, and in Table 19–1, we describe the behavioral impact of having a partner with hearing loss. CPs must continually put forth extra effort to ensure successful communication. This includes the need to: get up and walk over to one’s PHL to make speechreading available, repeat oneself frequently, and speak loudly (Brooks et al., 2001; Hétu et al., 1993; Scarinci et al., 2008). This can become exhausting when these behaviors are required recurrently. CPs may also need to take over their partner’s previous duties, such as speaking on the telephone or shopping in the community (Hallam et al., 2008; Scarinci et al., 2008).

Hearing loss has a great impact on the social life of the CP (see Table 19–1). Their social lives are reduced and restricted as their PHLs avoid social situations such as parties and restaurants (Brooks et al., 2001; Hallam et al., 2008; Hétu et al., 1993; Scarinci et al., 2008). CPs experience the added stress and burden of having to act as an interpreter at social gathering and in other public situations, such as at the doctor’s office (Hétu et al., 1993).

Table 19–2 shows how CPs describe the impact of hearing loss on their relationship with their PHL. CPs spend less time with their PHL and less time communicating (Brooks et al., 2001; Hétu et al., 1993; Scarinci et al., 2008). When the CP finds that is it too much effort to share a funny story that happened at work or it is just too difficult to relate a phone conversation with a family member, CPs experience a loss of intimacy and spontaneity in the relationship with their PHL (Hétu et al., 1993; Scarinci et al., 2008). Finally, CPs express a feeling of loss due to changes in their relationship due to the hearing loss. Adult children discuss the loss of the relationship with their parent that existed prior to the hearing loss. One participant noted “We are just like two people going someplace, we are not engaging, and that’s not the way it was” (Preminger et al., 2015, p. 725).

Measurement of Hearing Loss-Related Quality of Life (HLQoL) in Communication Partners

We can quantify the effects of hearing loss described in the previous section in a number of ways. Here, we review three ways in which hearing loss-related quality of life (HLQoL) can be measured within members of a couple in which one of the partners has hearing loss. The participation restrictions and activity limitations associated with hearing loss can be measured in the PHL. This is often measured by the Hearing Handicap for the Elderly (Ventry & Weinstein, 1982) in individuals 65 and older and by the Hearing Handicap for Adults in those younger than 65 (Newman, Jacobson, Hug, Weinstein, & Malinoff, 1991). As these scales are very similar (three out of 25 questions are different between the two scales), they will be referred to here as the HHI. These 25-item scales measure the emotional effects and the social/situational effects of living with hearing loss. For example, an item from the emotional subscale is “Does your hearing problem cause you to feel embarrassed when meeting new people?” while an item from the social subscale is “Does your hearing problem cause you to avoid groups of people?” PHLs respond yes (4 points), sometimes (2 points), or no (0 points) to each question; a total score can range from 0 (no reported hearing handicap) to 100 (extreme hearing handicap).

In the health care literature, proxy ratings of health-related quality of life (QoL) are typically given by family members when the person with a specified condition cannot complete a report. For example, in patients with dementia, a caregiver can report QoL (Hickey, Barker, McGee, & O’Boyle, 2005). However, in the hearing impairment literature, proxy reports are also used to determine how the CP perceives the activity limitations and participation restriction experienced by their PHLs. Proxy reports of HLQoL can be measured with the HHI-SO, where the SO indicates “significant other” (Newman & Weinstein, 1988). To reiterate, in the HHI the PHL may respond to a question such as “Does a hearing problem cause you to feel embarrassed when meeting new people?” while in the proxy version (HHI-SO) the CP responds to the question “Does a hearing problem cause your SO to feel embarrassed when meeting new people?” (Newman & Weinstein, 1988; Ventry & Weinstein, 1982).

It is often informative to consider the similarities or differences in HLQoL reports of PHLs and proxy reports of their CPs. Figure 19–1 shows the results when PHLs completed the HHI and CPs (mostly spouses) completed the HHI-SO across six different studies. Newman and Weinstein (1986) were the first to measure reports of HLQoL within members of a couple and they found that PHLs reported significantly more hearing handicap than that reported by their CPs. The authors noted that “Although an individual may be affected by a family member’s hearing loss, the spouse may not be able to understand the total impact of hearing loss on a hearing-impaired person’s psychosocial well-being” (p. 113). These authors raised two important points. The first is that proxy reports of HLQoL do not measure the third-party disability that arises from being married to a PHL (this will be discussed in greater detail in a later section). The second point is that HHI scores in the PHL are often incongruent with the HHI-SO scores in the CP (Preminger & Meeks, 2010a). Here, we will assume that scores within 14 points are congruent, based on 90% critical differences for PHLs on the HHI as reported by Chisolm et al. (2005).

Across the six studies shown in Figure 19–1, four of the studies found significantly greater reports of hearing handicap in the PHLs and two of the studies reported significantly greater proxy reports of hearing handicap in the CP. Numerous reasons have been proposed for these discrepant findings: personality factors (Newman & Weinstein, 1986; Preminger & Meeks, 2010b), degree of hearing loss in the PHL (Newman & Weinstein, 1986), and degree of hearing handicap reported by the PHL (Preminger, 2002). Another important factor to consider is that in the two Chmiel and Jerger studies (1993, 1996), the majority of PHLs had not yet sought amplification for their hearing loss, while the majority of PHLs in the other four previously cited studies were hearing aid users; thus incongruences in HLQoL within some couples may be explained by the stage of the PHL in the patient journey (Manchaiah, Stephens, & Meredith, 2011).

Based on the data shown in Figure 19–1, it is evident that in some couples a CP may underreport a partner’s HLQoL, while in other couples a spouse may overreport it. It is useful to consider congruence in perceptions of HLQoL as this may have implications for treatment (Preminger & Meeks, 2010b). For example, a CP whose proxy report underestimates his/her spouse’s HLQoL may be less likely to practice effective communication strategies and may not encourage his/her partner to seek AR. In fact, difference scores between HHI and HHI-SO can be measured before and after AR to measure AR effectiveness (Newman & Weinstein, 1988; Preminger & Meeks, 2010a).

Earlier in the chapter, third-party disability was defined as the participation restrictions and activity limitations that arise from being partnered to a PHL. These effects are outlined in Tables 19–1 and 19–2. There are two known scales available to measure this third-party disability: the Significant Other Scale for Hearing Disability (SOS-HEAR) (Scarinci, Worrall, & Hickson, 2009a) and the Hearing Impairment Impact—Significant Other Profile (HII-SOP) (Preminger & Meeks, 2012). The HII-SOP is a 20-item scale with three subscales and is shown in Appendix 19–A. Relationships and Emotions is an 11-item subscale that describes the impact of the hearing loss on the marital relationship and the emotions associated with hearing loss reported by the spouse; for example, “Do you get irritated when you try to talk with your SO but she/he cannot understand you?” and “Because of your SO’s hearing loss, do you talk less often than you used to?” Communication Strategies is a five-item subscale that describes the strategies employed by the CP to improve communication; for example, “Do you have to make sure your SO is looking at you when you speak to him/her?” Social Impact is a four-item subscale that describes the effect of the hearing loss on the social life as experienced by the CP; for example, “Do you and your SO avoid going to restaurants because of your SO’s hearing loss?” CPs can respond yes (5 points), sometimes (2.5 points), or no (0 points) to each question. As the HII-SOP was modeled on the HHI and HHI-SO, scores can range from 0 to 100. The HII-SOP has adequate internal consistency reliability, construct validity, and test-retest reliability (Preminger & Meeks, 2012). The 95% critical difference value is 19.7 points; accordingly, scores of 20 to 39 reflect mild third-party disability, scores of 40 to 59 reflect moderate third-party disability, and scores greater than 60 reflect severe third-party disability associated with hearing loss (Preminger & Meeks, 2012).

We can consider the HLQoL scores for two couples to understand the value of making these measurements in both the PHL and the CP. The black bars in Figure 19–2 show the HLQoL before the PHL completed a four-session group AR (GAR) program. HLQoL in the PHL was measured with the HHI, the proxy report in the CP was measured with the HHI-SO, and the third-party disability report in the CP was measured with the HII-SOP. In this case the PHL is a 63-year-old female with symmetrical hearing loss (three-frequency pure tone average [PTA] = 78 dB HL). As measured by the Quick Speech in Noise test (QuickSIN) (Etymotic Research, 2001), this PHL needed sentence materials at a 19 dB signal to noise ratio (SNR) to understand 50% of the key words correctly. In other words, this PHL has a severe hearing loss with poor speech understanding in noise. At the time of the first evaluation, this PHL had worn binaural hearing aids for 25 years. Prior to participating in GAR, reports of HLQoL were incongruent. The wife with hearing loss reported an HHI score of 74, and her husband’s proxy report was 26 points lower. Additionally, the husband reported only a mild third-party disability with a HII-SOP score of 35. After completing the group AR program, the PHL’s HLQoL score improved by 28 points, a significant improvement (Newman, Weinstein, Jacobson, & Hug, 1991). Additionally, the proxy report of the CP also showed an improvement in HLQoL; consequently, the reports of the PHL and CP remained incongruent post GAR with a difference score of 20. Note that the third-party disability reported by the CP did not change post-GAR. This is understandable, as the CP did not participate in the program. In summary, while the HLQoL reported by the PHL did improve, this individual is still reporting a mild to moderate hearing handicap. The fact that the post-treatment proxy report is still 20 points lower in the CP suggests that this CP still does not understand the participation restrictions and activity limitations experienced by his wife. Thus, he may not understand that his communication behaviors could influence his wife’s HLQoL.

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