Functional Hearing Difficulties in Veterans: Retrospective Chart Review of Auditory Processing Assessments in the VA Health Care System.

PURPOSE: Approximately 23 million Americans might have functional hearing difficulties (FHDs) that are not well explained by their audiometric thresholds. Clinical management of patients with FHDs is the subject of considerable debate, with few evidence-based guidelines to direct patient care. A better understanding of the characteristics of patients who seek help for FHDs, as well as current audiological management practices, is needed to direct research efforts to the areas greatest opportunity for advancement of clinical care. METHOD: A retrospective chart review was conducted examining the medical records of a random sample of 100 Veterans who underwent auditory processing assessments across the VA Health Care System between 2008 and 2020. RESULTS: Patients were young to middle-age, often with previous traumatic brain injury or blast exposure. Mental health, sleep, and pain disorders were common. No consistent relationships emerged between specific patient factors and domains of auditory processing deficits. Low-gain hearing aids were provided to 35 patients, 69% of whom continued wearing their hearing aids for at least 2 years. CONCLUSION: Future research should address the potential overlap in symptoms and treatment for comorbid health conditions and FHDs, as well as the conditions underlying successful hearing aid use in this patient population.

Prevalence of Somatosensory Tinnitus in Veterans With Tinnitus.

OBJECTIVES: The primary objective was to estimate the prevalence of somatosensory tinnitus (ST) among Veterans with tinnitus. DESIGN: Three hundred four Veterans with tinnitus were phone screened for ST by performing and reporting on a series of head/neck/jaw maneuvers. A random sample of 12 individuals who screened positive and five who screened negative attended an in-person visit to confirm the presence/absence of ST. RESULTS: Of the 304 Veterans, 12 could not complete the screening maneuvers, 205 screened positive, and 87 screened negative. A Bayesian estimator that combines phone screening and in-person exam results establishes the prevalence of ST among Veterans with tinnitus at 56% with a 90% Bayesian confidence interval of 45% to 65%. CONCLUSIONS: At least half of Veterans with tinnitus have ST, suggesting that a sizable at-need population exists. Treatment addressing the biomechanical component has the potential to improve tinnitus symptoms.

Examining the Utility of Photovoice as an Audiological Counseling Tool.

BACKGROUND: Photovoice is a participatory action research method in which people take photographs to represent real-world experiences, so that issues of interest/concern can be documented. There are no published studies in which photovoice has been used in audiological rehabilitation (AR). The purpose of this feasibility study was to examine whether photovoice could have application in audiology. PURPOSE: A feasibility study was designed to determine whether photovoice could be adapted for use as a clinical auditory rehabilitation tool (1) to facilitate provision of tailored communication strategy counseling, (2) as a post-hearing aid fitting counseling tool, (3) to enhance communication between partners regarding hearing loss, and (4) to provide an understanding of the emotional impacts of hearing loss. RESEARCH DESIGN: In this combined qualitative and quantitative feasibility study, a photovoice intervention was given to four groups of participants. STUDY SAMPLE: Twenty-four individuals were recruited from a research subject data repository at the National Center for Rehabilitative Auditory Research. DATA COLLECTION AND ANALYSIS: The study involved two visits to the laboratory during which participants received instruction in photovoice methodology (visit 1) and then, one to two weeks later, discussed their photographs during a debriefing session (visit 2). RESULTS: The mean number of photographs taken by participants was 12.6 (range: 4-29); the mean duration of the debriefing sessions was 40:39 min:sec (range: 14:30-66:22 min:sec). Participants reported that participating had made them think more about their hearing problems, appreciate their hearing aids more, and be more aware of the situations in which their hearing aids did and did not help. The taking and discussion of the photographs was also described as a learning tool, and it had facilitated conversations with others about hearing problems. Participants who completed the study with their communication partner (use case 3) said it had assisted with problem-solving and gave insight into the perspective of their partner. The research team noted that photovoice facilitated highly tailored counseling and provision of evidence-based recommendations for hearing assistive technology, enhanced interaction between communication partners, provided insight into participants' lifestyle and communication needs, and seemed to generate rapport and trust. CONCLUSIONS: This feasibility study indicated that participants were willing to engage in photovoice and that it could be used to guide selection of rehabilitation recommendations and for postfitting counseling. Its application in audiological practice would seem timely and valuable for improving patient-centered and family-centered AR.

Development of a hearing help-seeking questionnaire based on the theory of planned behavior.

OBJECTIVE: Our objective was to develop and assess a questionnaire measuring the constructs of the theory of planned behaviour (TPB) regarding older adults' behaviours towards seeking a hearing test. DESIGN: Older adults who failed a hearing screening completed a newly developed Theory of Planned Behavior-Hearing Help Seeking (TPB-HHS) questionnaire. A principal components analysis (PCA) examined the factor structure of the questionnaire, and a reliability analysis determined the internal consistency of the factors. An examination of six-month follow-up data determined whether the questionnaire differentiated between individuals who did and did not seek out a hearing test by comparing their TPB-HHS scores. STUDY SAMPLE: Participants were 407 adults aged 50 to 89 recruited at community hearing screenings. RESULTS: PCA and reliability analyses resulted in a 4-factor, 18 item questionnaire. Three of four factors demonstrated acceptable internal consistency. The TPB-HHS explained 60.18% of the variance and factors were interpreted to be measuring the constructs of Intentions, Perceived Behavioral Control, Attitudes, and Subjective Norms. Individuals who sought a hearing test scored significantly higher on the Intentions, Perceived Behavioral Control, and Attitudes scales than those who did not. CONCLUSIONS: The TPB-HHS provides insight into underlying psychological mechanisms that drive behaviours related to hearing help-seeking in older adults.

Hearing Screening in the Community.

BACKGROUND: Adults typically wait 7-10 yr after noticing hearing problems before seeking help, possibly because they are unaware of the extent of their impairment. Hearing screenings, frequently conducted at health fairs, community events, and retirement centers can increase this awareness. To our knowledge, there are no published studies in which testing conditions and outcomes have been examined for multiple "typical screening events." PURPOSE: The purpose of this article is to report hearing screening outcomes for pure tones and self-report screening tests and to examine their relationship with ambient noise levels in various screening environments. STUDY SAMPLE: One thousand nine hundred fifty-four individuals who completed a hearing screening at one of 191 community-based screening events that took place in the Portland, OR, and Tampa, FL, metro areas. DATA COLLECTION AND ANALYSIS: The data were collected during the recruitment phase of a large multisite study. All participants received a hearing screening that consisted of otoscopy, pure-tone screening, and completion of the Hearing Handicap Inventory-Screening Version (HHI-S). In addition, ambient sound pressure levels were measured just before pure-tone testing. RESULTS: Many more individuals failed the pure-tone screening (n = 1,238) and then failed the HHI-S (n = 796). The percentage of individuals who failed the pure-tone screening increased linearly with age from <20% for ages <45 yr to almost 100% for individuals aged ≥85 yr. On the other hand, the percentage of individuals who failed the HHI-S remained unchanged at approximately 40% for individuals aged ≥55 yr. Ambient noise levels varied considerably across the hearing screening locations. They impacted the pure-tone screen failure rate but not the HHI-S failure rate. CONCLUSIONS: It is important to select screening locations with a quiet space for pure-tone screening, use headphones with good passive attenuation, measure sound levels regularly during hearing screening events, halt testing if ambient noise levels are high, and/or alert individuals to the possibility of a false-positive screening failure. The data substantiate prior findings that the relationship between pure-tone sensitivity and reported hearing loss changes with age. Although it might be possible to develop age-specific HHI-S failure criteria to adjust for this, such an endeavor is not recommended because perceived difficulties are the best predictor of hearing health behaviors. Instead, it is proposed that a public health focus on education about hearing and hearing loss would be more effective.

Impact of Hearing Loss and Amplification on Performance on a Cognitive Screening Test.

BACKGROUND: There have been numerous recent reports on the association between hearing impairment and cognitive function, such that the cognition of adults with hearing loss is poorer relative to the cognition of adults with normal hearing (NH), even when amplification is used. However, it is not clear the extent to which this is testing artifact due to the individual with hearing loss being unable to accurately hear the test stimuli. PURPOSE: The primary purpose of this study was to examine whether use of amplification during cognitive screening with the Montreal Cognitive Assessment (MoCA) improves performance on the MoCA. Secondarily, we investigated the effects of hearing ability on MoCA performance, by comparing the performance of individuals with and without hearing impairment. STUDY SAMPLE: Participants were 42 individuals with hearing impairment and 19 individuals with NH. Of the individuals with hearing impairment, 22 routinely used hearing aids; 20 did not use hearing aids. DATA COLLECTION AND ANALYSIS: Following a written informec consent process, all participants completed pure tone audiometry, speech testing in quiet (Maryland consonant-nucleus-consonant [CNC] words) and in noise (Quick Speech in Noise [QuickSIN] test), and the MoCA. The speech testing and MoCA were completed twice. Individuals with hearing impairment completed testing once unaided and once with amplification, whereas individuals with NH completed unaided testing twice. RESULTS: The individuals with hearing impairment performed significantly less well on the MoCA than those without hearing impairment for unaided testing, and the use of amplification did not significantly change performance. This is despite the finding that amplification significantly improved the performance of the hearing aid users on the measures of speech in quiet and speech in noise. Furthermore, there were strong correlations between MoCA score and the four frequency pure tone average, Maryland CNC score and QuickSIN, which remain moderate to strong when the analyses were adjusted for age. CONCLUSIONS: It is concluded that the individuals with hearing loss here performed less well on the MoCA than individuals with NH and that the use of amplification did not compensate for this performance deficit. Nonetheless, this should not be taken to suggest the use of amplification during testing is unnecessary because it might be that other unmeasured factors, such as effort required to perform or fatigue, were decreased with the use of amplification.

A Randomized Controlled Trial to Evaluate Approaches to Auditory Rehabilitation for Blast-Exposed Veterans with Normal or Near-Normal Hearing Who Report Hearing Problems in Difficult Listening Situations.

BACKGROUND: Blast exposure is a major source of injury among Service members in the Iraq and Afghanistan conflicts. Many of these blast-exposed veterans report hearing-related problems such as difficulties understanding speech in noise and rapid speech, and following instructions and long conversations that are disproportionate to their measured peripheral hearing sensitivity. Evidence is mounting that these complaints result from damage to the central auditory processing system. PURPOSE: To evaluate the effectiveness of audiological rehabilitative interventions for blast-exposed veterans with normal or near-normal peripheral hearing and functional hearing difficulties. RESEARCH DESIGN: A randomized controlled trial with four intervention arms. STUDY SAMPLE: Ninety-nine blast-exposed veterans with normal or near-normal peripheral hearing who reported functional hearing difficulties. INTERVENTION: Four interventions were compared: compensatory communication strategies (CCS) education, CCS and use of a personal frequency modulation system (FM + CCS), CCS and use of an auditory training program (AT + CCS), and use of all three interventions combined (FM + AT + CCS). DATA COLLECTION AND ANALYSIS: All participants tested before, and immediately following an 8-week intervention period. The primary outcome measures upon which the study was powered assessed speech understanding in noise and self-reported psychosocial impacts of the intervention. In addition, auditory temporal processing, auditory working memory, allocation of attention, and hearing and cognitive self-report outcomes were assessed. RESULTS: Use of FM + CCS resulted in significant benefit for speech understanding in noise and self-reported hearing benefits, and FM + AT + CCS provided more self-reported cognitive benefits than FM + CCS, AT + CCS, or CCS. Further, individuals liked and reported using the FM system, but there was poor adherence to and high attrition among individuals assigned to receive AT. CONCLUSIONS: It is concluded that a FM system (or remote microphone via Bluetooth system) is an effective intervention for blast-exposed veterans with normal or near-normal hearing and functional hearing difficulties and should be routinely considered as an intervention approach for this population when possible.

Development and Pilot Evaluation of a Novel Theory-Based Intervention to Encourage Help-Seeking for Adult Hearing Loss.

BACKGROUND: Health behavior theories can provide an understanding of hearing health behaviors and, more importantly, can be used to develop theoretically based strategies to change these health behaviors. PURPOSE: To develop a theory-based brief intervention to increase help-seeking for adult hearing loss and to conduct a pilot study to evaluate its feasibility, effectiveness, and impact on hearing beliefs and behaviors. RESEARCH DESIGN: An intervention was designed that could be easily administered by a health-care provider who does not have expertise in audiology-such as a primary care physician, community nurse, or social worker. The intervention aims to alter perceived benefit, severity, cues to action, and self-efficacy for seeking help by providing experiential/affective messaging and simultaneously providing intrinsic motivation for the recipient to seek hearing help. To first determine whether this intervention changed beliefs and increased help-seeking behavior, this study was conducted in a hearing research laboratory setting. STUDY SAMPLE: A total of 101 adults aged 50-89 yr were recruited within 6 months of having attended an appointment at a primary care clinic at the VA Portland Health Care System. All were sent a letter inviting them to participate in a study if they had trouble with their hearing but had not had a scheduled hearing test or worn hearing aids in the prior 5 yr and also had functional oral and written English. Data from 87 individuals were available for analysis. INTERVENTION: The intervention is designed for use in any health-care setting in which a health-care provider can facilitate a conversation about hearing. On arrival at a health-care facility, recipients are provided with nine emotionally evocative color photographs to prompt reflection on ways in which hearing difficulties impact them. A discussion with a health-care provider (facilitator) follows, during which recipients may identify the negative impacts of their hearing loss. If the recipient identifies negative impacts, the facilitator suggests that he or she consider having a hearing test and provides a list of local hearing-health professionals. DATA COLLECTION AND ANALYSIS: Participants completed baseline questionnaires assessing hearing beliefs and attitudes. They were then randomly assigned either to the group receiving the study intervention or to a control group. Six months after study enrollment, participants reported whether they had sought help for their hearing and completed a second set of questionnaires. RESULTS: Twelve of 41 individuals (29.3%) in the intervention group and 7 of 46 individuals (15.2%) in the control group sought help within the 6-month follow-up period. A χ² test showed these numbers did not differ significantly; however, the odds ratio of having had a hearing test were 2.3 times greater for those who received the intervention than for those who did not. CONCLUSIONS: Despite not reaching statistical significance, the odds ratio suggests that the theory-based brief intervention is worthy of additional examination. We intend to work with health-care providers to conduct a larger study to investigate whether the intervention has value in the real world.

Examination of Individual Differences in Outcomes From a Randomized Controlled Clinical Trial Comparing Formal and Informal Individual Auditory Training Programs.

PURPOSE: The purpose of this study was to determine if patient characteristics or clinical variables could predict who benefits from individual auditory training. METHOD: A retrospective series of analyses were performed using a data set from a large, multisite, randomized controlled clinical trial that compared the treatment effects of at-home auditory training programs in bilateral hearing aid users. The treatment arms were (a) use of the 20-day computerized Listening and Communication Enhancement program, (b) use of the 10-day digital versatile disc Listening and Communication Enhancement program, (c) use of a placebo "books-on-tape" training, and (d) educational counseling (active control). Multiple linear regression models using data from 263 participants were conducted to determine if patient and clinical variables predicted short-term improvement on word-recognition-in-noise abilities, self-reported hearing handicap, and self-reported hearing problems. RESULTS: Baseline performance significantly predicted performance on each variable, explaining 11%-17% of the variance in improvement. The treatment arm failed to emerge as a significant predictor with other clinical variables explaining less than 9% of the variance. CONCLUSION: These results suggest that hearing aid users who have poorer aided word-recognition-in-noise scores and greater residual activity limitations and participation restrictions will show the largest improvement in these areas.

Health behavior theories as predictors of hearing-aid uptake and outcomes.

OBJECTIVE: To understand hearing behaviors of adults seeking help for the first time through the application of two models of health behavior change: the transtheoretical model and the health belief model. DESIGN: The relationships between attitudes and beliefs were examined relative to hearing-aid uptake and outcomes six months later. STUDY SAMPLE: One hundred and sixty adults completed the University of Rhode Island change assessment (targeting the transtheoretical model), and the hearing beliefs questionnaire (targeting the health belief model), as well as the hearing handicap inventory and the psychosocial impact of hearing loss scale, within two months of an initial hearing assessment. Six months later, participants completed these same questionnaires, while those who had taken up hearing aids also completed hearing-aid outcome questionnaires. RESULTS: (1) Attitudes and beliefs were associated with future hearing-aid uptake, and were effective at modeling this behavior; (2) attitudes and beliefs changed following behavior change, and (3) attitudes and beliefs following behavior change were better predictors of hearing-aid outcomes than pre-behavior change attitudes and beliefs. CONCLUSION: A counseling-based intervention targeting the attitudes and beliefs assessed by the transtheoretical model and the health belief model has the potential to increase uptake of hearing health care.

A Randomized Control Trial: Supplementing Hearing Aid Use with Listening and Communication Enhancement (LACE) Auditory Training.

OBJECTIVE: To examine the effectiveness of the Listening and Communication Enhancement (LACE) program as a supplement to standard-of-care hearing aid intervention in a Veteran population. DESIGN: A multisite randomized controlled trial was conducted to compare outcomes following standard-of-care hearing aid intervention supplemented with (1) LACE training using the 10-session DVD format, (2) LACE training using the 20-session computer-based format, (3) placebo auditory training (AT) consisting of actively listening to 10 hr of digitized books on a computer, and (4) educational counseling-the control group. The study involved 3 VA sites and enrolled 279 veterans. Both new and experienced hearing aid users participated to determine if outcomes differed as a function of hearing aid user status. Data for five behavioral and two self-report measures were collected during three research visits: baseline, immediately following the intervention period, and at 6 months postintervention. The five behavioral measures were selected to determine whether the perceptual and cognitive skills targeted in LACE training generalized to untrained tasks that required similar underlying skills. The two self-report measures were completed to determine whether the training resulted in a lessening of activity limitations and participation restrictions. Outcomes were obtained from 263 participants immediately following the intervention period and from 243 participants 6 months postintervention. Analyses of covariance comparing performance on each outcome measure separately were conducted using intervention and hearing aid user status as between-subject factors, visit as a within-subject factor, and baseline performance as a covariate. RESULTS: No statistically significant main effects or interactions were found for the use of LACE on any outcome measure. CONCLUSIONS: Findings from this randomized controlled trial show that LACE training does not result in improved outcomes over standard-of-care hearing aid intervention alone. Potential benefits of AT may be different than those assessed by the performance and self-report measures utilized here. Individual differences not assessed in this study should be examined to evaluate whether AT with LACE has any benefits for particular individuals. Clinically, these findings suggest that audiologists may want to temper the expectations of their patients who embark on LACE training.

Description of Adults Seeking Hearing Help for the First Time According to Two Health Behavior Change Approaches: Transtheoretical Model (Stages of Change) and Health Belief Model.

OBJECTIVES: Several models of health behavior change are commonly used in health psychology. This study applied the constructs delineated by two models-the transtheoretical model (in which readiness for health behavior change can be described with the stages of precontemplation, contemplation and action) and the health belief model (in which susceptibility, severity, benefits, barriers, self-efficacy, and cues to action are thought to determine likelihood of health behavior change)-to adults seeking hearing help for the first time. DESIGN: One hundred eighty-two participants (mean age: 69.5 years) were recruited following an initial hearing assessment by an audiologist. Participants' mean four-frequency pure-tone average was 35.4 dB HL, with 25.8% having no hearing impairment, 50.5% having a slight impairment, and 23.1% having a moderate or severe impairment using the World Health Organization definition of hearing loss. Participants' hearing-related attitudes and beliefs toward hearing health behaviors were examined using the University of Rhode Island Change Assessment (URICA) and the health beliefs questionnaire (HBQ), which assess the constructs of the transtheoretical model and the health belief model, respectively. Participants also provided demographic information, and completed the hearing handicap inventory (HHI) to assess participation restrictions, and the psychosocial impact of hearing loss (PIHL) to assess the extent to which hearing impacts competence, self-esteem, and adaptability. RESULTS: Degree of hearing impairment was associated with participation restrictions, perceived competence, self-esteem and adaptability, and attitudes and beliefs measured by the URICA and the HBQ. As degree of impairment increased, participation restrictions measured by the HHI, and impacts of hearing loss, as measured by the PIHL, increased. The majority of first-time help seekers in this study were in the action stage of change. Furthermore, relative to individuals with less hearing impairment, individuals with more hearing impairment were at more advanced stages of change as measured by the URICA (i.e., higher contemplation and action scores relative to their precontemplation score), and they perceived fewer barriers and more susceptibility, severity, benefits and cues to action as measured by the HBQ. Multiple regression analyses showed participation restrictions (HHI scores) to be a highly significant predictor of stages of change explaining 30% to 37% of the variance, as were duration of hearing difficulty, and perceived benefits, severity, self-efficacy and cues to action assessed by the HBQ. CONCLUSIONS: The main predictors of stages of change in first-time help seekers were reported participation restrictions and duration of hearing difficulty, with constructs from the health belief model also explaining some of the variance in stages of change scores. The transtheoretical model and the health belief model are valuable for understanding hearing health behaviors and can be applied when developing interventions to promote help seeking.

Auditory difficulties in blast-exposed Veterans with clinically normal hearing.

UNLABELLED: Vast numbers of blast-injured Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn personnel report postconcussive symptoms that include headache, dizziness, poor memory, and difficulty concentrating. In addition, many report hearing problems, such as difficulty understanding speech in noise, yet have no measureable peripheral auditory deficits. In this article, self-report and performance-based measures were used to assess 99 blast-exposed Veterans. All participants reported auditory problems in difficult listening situations but had clinically normal hearing. Participants' scores on self-report questionnaires of auditory difficulties were more similar to scores of older individuals with hearing impairment than to those of younger individuals with normal hearing. Participants showed deficits relative to published normative data on a number of performance-based tests that have demonstrated sensitivity to auditory processing deficits. There were several measures on which more than the expected number of participants (15.9%) performed one or more standard deviations below the mean. These were assessments of speech understanding in noise, binaural processing, temporal resolution, and speech segregation. Performance was not universally poor, with approximately 53% of participants performing abnormally on between 3 and 6 of the 10 measures. We concluded that participants exhibited task-specific deficits that add to the evidence suggesting that blast injury results in damage to the central auditory system. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov; Approaches to Auditory Rehabilitation for Mild Traumatic Brain Injury (mTBI); NCT00930774; https://clinicaltrials.gov/ct2/show/NCT00930774?term=NCT00930774&rank=1.

Validation of a novel combination hearing aid and tinnitus therapy device.

OBJECTIVES: Most patients with tinnitus also have hearing loss. Hearing aids have been well-documented to provide amelioration for both hearing and tinnitus problems. Some hearing aids have built-in noise/sound generators that are intended to provide added benefit to patients with tinnitus. It has not been proven, however, whether these "combination instruments" are more effective for tinnitus management than hearing aids alone. The purpose of this study was to collect initial data addressing this question. DESIGN: Thirty individuals meeting study requirements (bothersome tinnitus, hearing aid candidate, and no use of hearing aids for the previous 12 months) were enrolled. All participants initially completed the primary outcome questionnaire (Tinnitus Functional Index [TFI]) and then returned to be fitted with combination instruments. The hearing aid portion of the devices was adjusted to optimize hearing ability. Participants were then randomized to either the experimental group (n = 15) or the control group (n = 15). The experimental group had the noise feature of the instruments activated and adjusted to achieve optimal relief from tinnitus. The control group did not have the noise portion activated. Following the hearing aid fitting, all study participants also received brief tinnitus counseling. Participants returned 1 to 2 weeks later for a follow-up appointment to confirm proper fit of the instruments and to make any necessary programming adjustments. Additionally, they returned 3 months after the fitting to complete the TFI, which also concluded their participation in the study. RESULTS: Both groups revealed significant improvement, as indicated by reductions in mean TFI index scores. Differences between groups at 3 months were not statistically significant. However, the experimental group showed a mean reduction in the TFI score that was 6.4 points greater than that for the control group. The difference approached significance (p = 0.09), suggesting that a larger group of participants may have resulted in a significant difference between groups. This possibility is tempered by the fact that effect sizes, which control for variation, were very similar between groups. CONCLUSIONS: Results of this study suggest that the use of hearing aids alone or hearing aids plus the use of sound generators both provide significant benefit with respect to alleviating effects of tinnitus. A larger controlled clinical trial is needed to obtain more definitive results regarding the two configurations of hearing aids.

Development and evaluation of a questionnaire to assess knowledge, attitudes, and behaviors towards hearing loss prevention.

OBJECTIVE: To develop and evaluate a questionnaire assessing knowledge, attitudes, and behaviors (KAB) as they pertain to hearing conservation, using the constructs of the health belief model (HBM). DESIGN: The KAB was completed by 235 participants. Relationships between knowledge and attitudes about hearing and hearing conservation, participation in noisy activities, and use of hearing protection were examined. STUDY SAMPLE: 117 males and 118 females aged between 18 and 80 years (mean = 42.3, SD = 4.1) recruited from the Portland VA Medical Center, local universities, and a community college. RESULTS: Knowledge scores ranged from 15.6% to 93.8%. Factor analyses revealed six attitude factors, interpreted as measuring perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, and cues to action. Over 95% of participants routinely participated in at least one noisy activity but few used hearing protection while doing so. The attitude scores of individuals who used hearing protection differed significantly from the scores of those who did not. CONCLUSIONS: Significant relationships between use of hearing protection and scores on the KAB provide validation that the HBM is a valuable framework for understanding hearing health behaviors, and evidence that the KAB is a valid tool for assessing these attitudes and behaviors.

Learning to listen again: the role of compliance in auditory training for adults with hearing loss.

PURPOSE: To examine the role of compliance in the outcomes of computer-based auditory training with the Listening and Communication Enhancement (LACE) program in Veterans using hearing aids. METHOD: The authors examined available LACE training data for 5 tasks (i.e., speech-in-babble, time compression, competing speaker, auditory memory, missing word) from 50 hearing-aid users who participated in a larger, randomized controlled trial designed to examine the efficacy of LACE training. The goals were to determine: (a) whether there were changes in performance over 20 training sessions on trained tasks (i.e., on-task outcomes); and (b) whether compliance, defined as completing all 20 sessions, vs. noncompliance, defined as completing less than 20 sessions, influenced performance on parallel untrained tasks (i.e., off-task outcomes). RESULTS: The majority, 84% of participants, completed 20 sessions, with maximum outcome occurring with at least 10 sessions of training for some tasks and up to 20 sessions of training for others. Comparison of baseline to posttest performance revealed statistically significant improvements for 4 of 7 off-task outcome measures for the compliant group, with at least small (0.2 < d < 0.3) Cohen's d effect sizes for 3 of the 4. There were no statistically significant improvements observed for the noncompliant group. CONCLUSION: The high level of compliance in the present study may be attributable to use of systematized verbal and written instructions with telephone follow-up. Compliance, as expected, appears important for optimizing the outcomes of auditory training. Methods to improve compliance in clinical populations need to be developed, and compliance data are important to report in future studies of auditory training.

Application of the health belief model: development of the hearing beliefs questionnaire (HBQ) and its associations with hearing health behaviors.

OBJECTIVE: To develop a hearing beliefs questionnaire (HBQ) that assesses hearing beliefs within the constructs of the health belief model, and to investigate whether HBQ scores are associated with hearing health behaviors. DESIGN: A 60-item version of the questionnaire was developed and completed by 223 participants who also provided information about their hearing health behaviors (help seeking, hearing-aid acquisition, and hearing-aid use). STUDY SAMPLE: Individuals aged between 22 and 90 years recruited from a primary care waiting area at a Veterans hospital. Seventy-six percent were male, 80% were Veterans. RESULTS: A 26-item version of the HBQ with six scales was derived using factor analysis and reliability analyses. The scales measured: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, and cues to action. HBQ scores differed significantly between individuals with different hearing health behaviors. Logistic regression analyses resulted in robust models of hearing health behaviors that correctly classified between 59% and 100% of participant hearing health behaviors. CONCLUSIONS: The HBM appears to be an appropriate framework for examining hearing health behaviors, and the HBQ is a valuable tool for assessing hearing health beliefs and predicting hearing health behaviors.

First steps: exploring use of a prospective, office-based registry as the foundation for quality improvement in cardiology training.

BACKGROUND: Teaching practice-based learning and improvement and systems-based practice are challenging. Cardiology fellows at St John Hospital & Medical Center participate in a national registry of outpatient cardiology care. OBJECTIVE: We assessed the use of the registry, hypothesizing that it could serve as an effective foundation for studying ambulatory care, identifying gaps in care, and planning interventions to advance competence in practice-based learning and improvement and systems-based practice. METHODS: Starting in 2009, trainees prospectively entered data for ambulatory cardiac patients into the PINNACLE Registry database where compliance with 28 performance measures was calculated and reported quarterly. Fellows met with the program director individually and in groups to identify performance gaps and to develop and implement plans for quality improvement. Cardiology fellows were surveyed annually to assess this process. RESULTS: Through March 2012, the fellows had completed 2400 patient visits. Participation was feasible because it was cost neutral, with data form completion averaging 5 minutes. It was acceptable, with most fellows describing positive effects on practice-based learning and improvement without significant detriment to work flow. Performance achievement for drug therapies ranged from 69% (77 of 111) of the patients with atrial fibrillation receiving anticoagulation to 99% (486 of 489) of patients with coronary disease receiving lipid-lowering therapy. Gaps in system performance included low levels for diabetes screening (5%; 20 of 422) and lipid monitoring (10%; 58 of 573). Initial quality improvement projects addressed practice gaps with straightforward solutions. Improving system performance was more challenging. CONCLUSIONS: Using a registry in cardiology trainees' outpatient practice is feasible, acceptable, and valuable. It allows for planning and studying the effects of quality improvement projects.

Inducibility of paroxysmal atrial fibrillation by isoproterenol and its relation to the mode of onset of atrial fibrillation.

BACKGROUND: Isoproterenol has been used to assess inducibility during catheter ablation for paroxysmal PAF. However, no studies have determined the sensitivity and specificity of isoproterenol for the induction of AF. It also is not clear whether isoproterenol is equally effective in inducing AF in the clinical subtypes of vagotonic, adrenergic, and random AF. OBJECTIVE: To determine the sensitivity and specificity of isoproterenol for the induction of atrial fibrillation (AF). METHODS: Isoproterenol was infused at 5, 10, 15, and 20 microg/min at 2-minute intervals or until AF was induced in 20 control subjects with no history of AF and in 80 patients with PAF. RESULTS: Among the 20 control subjects, AF was induced by isoproterenol in one patient (5%). Among the 80 patients with PAF, persistent AF was induced in 67 patients (84%, P < 0.001). Isoproterenol induced AF in 15 of 17 patients (88%) with vagotonic AF, 11 of 11 patients (100%) with adrenergic AF, and 41 of 52 patients (79%) with random episodes of AF (P = 0.2). The yield of AF was 11% (9/80) after 5 microg/min, 28% (22/80) after 10 microg/min, 51% (40/78) after 15 microg/min, and 88% (67/76) after 20 microg/min of isoproterenol (P < 0.01). Isoproterenol had to be discontinued in four patients (5%) before reaching the maximum dose due to reversible chest pain or systolic blood pressure <85 mmHg. CONCLUSIONS: Isoproterenol at infusion rates up to 20 microg/min has a high sensitivity (88%) and specificity (95%) for induction of AF in patients with PAF, regardless of whether the clinical subtype is vagotonic, adrenergic, or random.