British Journal of Audiology, 1997,31,345-351

A randomized, controlled trial of the efficacy of a

communication course for first time hearing aid

Graham J. Beynon, Frances L. Thornton2and Chris Poo1e2

Audiology Department, Addenbrookess Hospital, Cambridge CB2 2QQ and zAudiology
Department, Stoke Mandeville Hospital, Aylesbury HP218AL

(Received 25 October 1996 accepted in revised form I7 June 1997)

Abstract
Many centres include a communication course as part of their auditory rehabilitation. These usually take
the form of a small group and include discussion of the effects of hearing loss, use of the hearing aid, hear-
ing tactics and lip reading. To investigate the efficacy of such a rehabilitation programme a randomized,
controlled trial of a communication course was undertaken. All subjects were first time hearing aid users;
handicap was measured using the Quantified Denver Scale of Communication Function (QDS) at the time
of hearing aid fitting, and then 13 weeks later. All subjects had a hearing aid follow-up appointment, but the
treatment group (n = 22) also underwent a four-week communication course, while the control group
(n = 25) had no further rehabilitation. The reduction in handicap measured by the change in QDS was sig-
nificantly greater for the treatment group than for the control group (Mann Whitney U test, tiedp value
= 0.014). This indicates that such a communication course is efficacious in reducing handicap. Further
research is required to identify the populations that will benefit most from such a course.

Key words: communication course, auditory rehabilitation

Introduction While observational studies can indicate t h e

T h e ultimate goal of a n auditory rehabilitation
programme is t o reduce t h e communication
handicap that hearing impaired people experi-
ence. While the fitting of a hearing aid is seen as a
main feature of auditory rehabilitation, there are
many further techniques used including Lip-read-
ing, listening training, hearing tactics, hearing aid
orientation and education regarding hearing
loss. Many centres in t h e UK offer these tech-
niques of rehabilitation in the form of a commu-
nication course comprising a small group of
hearing aid wearers meeting for a few weeks.
There is a need t o evaluate t h e efficacy of these
communication courses t o justify their existence.
Address for reprints: G.J. Beynon, Audiology Department,
Box 94, Addenbrookess Hospital, Hills Road, Cambridge
CB2 2QQ
expected outcome of a rehabilitation treatment,
it remains unknown whether t h e outcome
observed can b e attributed t o the rehabilitation
provided o r is the natural history for the condi-
tion. Therefore, in t h e case of aural rehabilita-
tion which includes a communication course it is
unknown whether the observed outcomes were
d u e t o t h e fitting of a hearing aid only and t h e
subsequent learning curve in hearing aid use, o r
whether the additional input from the communi-
cation course significantly affected t h e out-
comes. There is a need, therefore, for controlled
evaluations of such rehabilitation (Wertz, 1993;
Wilson, 1993).
Previous studies o n t h e efficacy of auditory
training rehabilitation have shown improvement
on clinical tests but mixed evidence for reduction

0300-536419713 10345+06 $03.50/0 0 1997 British Society of Audiology

346 Graham J. Beynon et al.
in handicap. For example, improvement in per-
formance on tasks such as consonant or speech
recognition tests compared has been shown to be
significantly greater in a group undergoing
auditory training compared to a control group
receiving no rehabilitation (Walden et al., 1981;
Rubinstein and Boothroyd, 1987). However, a
study examining the effect of an individual four-
week communication training programme,
which emphasized use of situational and linguis-
tic cues was not able to demonstrate any signifi-
cant reduction in self-perceived handicap in a
group of elderly adults compared with a control
group (Kricos et al., 1992). This study used the
Hearing Handicap Inventory for the Elderly
(HHIE) as its measure of handicap (Ventry and
Weinstein, 1982). A further study also using the
H H I E (Kricos and Holmes, 1996) examined a
controlled trial of active listening training. This
showed significant improvement in clinical tests
of auditory function (speech in noise tests) for the
treatment group compared with the control
group; in addition a similar improvement was
shown on a scale of psycho-social status, which
attempts to quantify an individuals adjustment
to having a hearing loss. However, these
improvements did not carry over to a reduction in
hearing handicap as measured by the HHIE.
Evidence for the efficacy of such rehabilitation
on hearing handicap has been provided by
Smaldino and Smaldino (1988) who compared a
control group receiving standard hearing aid ori-
entation to three experimental groups. The
experimental groups all received standard hear-
ing aid orientation and were then randomized
into three groups. The first group received addi-
tional information about their individual cogni-
tive learning style; the second group received this
cognitive information and a four-week audio-
logic rehabilitation programme; the third group
received the audiological rehabilitation pro-
gramme only. The effect on self-perceived handi-
cap was examined using the Hearing
Performance Inventory (Lamb et al., 1979),
which demonstrated that the two groups receiv-
ing audiologic rehabilitation had a significantly
larger reduction in self-perceived handicap than
those receiving other forms of therapy. Another
controlled trial of a group communication course
compared patients receiving a hearing aid fol-
lowed by a counselling based auditory rehabilita-
tion course with patients receiving a hearing aid
only (Abrams et al., 1992). This course utilized a
group setting with discussion of the effects of
hearing loss, speech reading skills, methods to
improve communication skills and use of assis-
tive devices. The affect on self-perceived handi-
cap was measured by the HHIE. This showed
that the group receiving the additional rehabilita-
tion had a significantly larger reduction in self-
perceived handicap.
There is mixed evidence, therefore, for the effi-
cacy of acommunication course in reducing hear-
ing handicap. Courses concentrating on auditory
training aspects of rehabilitation have shown sig-
nificant improvement on clinical tests but not any
carry over to reduction in handicap. Courses
utilizing group work and a wide range of informa-
tion and rehabilitative techniques appear to have
demonstrated significant reduction in hearing
handicap. This present study therefore proposed
to evaluate a communication course employing a
wide range of rehabilitative techniques by means
of a prospective, randomized, controlled trial.
Method
A prospective, randomized, controlled study of
the efficacy of a communication course was
undertaken. The patient population selected was
patients being fitted with hearing aids for the first
time. This reduced the effect of other variables
such as length of time that hearing aids had been
worn, and amount of previous advice regarding
use of the hearing aids. Only patients aged less
than 80 years of age were included to avoid com-
mon difficulties presented by the very elderly
(e.g. transportation, poor manual dexterity). The
authors felt that such patients require more indi-
vidualized rehabilitation than is available in the
course under investigation. Patients were ran-
domized into two groups: treatment and con-
trol. Randomization was by taking the last digit
of the patients hospital numbers and assigning a
group by whether the digit was an odd or an even
number. This took place at the initial fitting of the
hearing aid and thus avoided any possible selec-
tion bias. After the initial fitting patients were left
to wear the hearing aid for six weeks and then
returned for a follow-up appointment. This
appointment reviewed the success of the fitting
and the hearing aid was adjusted according to the
patients reports. After the follow-up appointment
those patients assigned to the treatment group
entered a four week communication course, the
content of which is described below. The control
group received no further appointments.
 Communication course for hearing aid users 347
For inclusion in the study the patients in the treat- hearing impairment. Instruction in the basic
ment group had to attend at least three of the four elements of lip-reading.
sessions of the course. The hearing loss of the Session 3: explanation and discussion of coping
patients was classified into mild (pure tone average strategies for better communication including
0.5-4 kHz <40 dBHL) and moderate (> 40 dBHL group discussion of finding solutions to com-
pure tone average 0.5-4 kHz 4 0 dBHL). munication problems.
The level of handicap experienced by the Session 4:further instruction in lip-reading and
patients was assessed using the Quantified Den- hearing tactics. Discussion of the stress and
ver Scale of Communication Function (QDS) anxiety that can be involved in communica-
(Schow and Nerbonne, 1980). (The original Den- tion and the use of relaxation techniques.
ver Scale of Communication Function was devel-
oped by Alpiner et al. (1971).) This was Results
administered at the time of the first fitting of the
This study evaluated hearing handicap by means
hearing aid, and then 13 weeks later after the endof a self-rated questionnaire at the time of hear-
of the communication course. The QDS was ing aid fitting, and then 13 weeks later, after the
developed to subjectively assess the communica- treatment group had completed a four-week
tion handicap experienced by hearing impaired communication course. Fifty-three patients were
adults with acquired hearing loss. It has four sub-
entered into the study: 26 into the treatment
scales covering the following areas: (1) self, group, and 27 into the control group. Six patients
which examines the affect of hearing impairment were dropped from the study, five from the treat-
on an individuals view of him- or herself and hisment group for failing to attend the requisite
or her attitudes to the hearing loss; (2) family,
three sessions, and one from the control group
which examines the affect of hearing impairment for failing to return the final questionnaire. There
on an individuals relationship with his or her were therefore 21 patients in the treatment
family; (3) sociallvocational, which examines group, and 26 in the control group. The treatment
the affect of a hearing impairment on an individ- group had 13 females and 8 males; the control
uals work role and common social environ- group had 14 females and 12 males. The average
ments; and (4) communication, which examines age was 68.8 years (range 47-80) for the treat-
the effect of a hearing impairment on communi- ment group, and 68.6 years for the control group
cation difficulties in a range of common situa- (range 50-80). The treatment group had 13
tions. There are 25 questions with each question patients with mild hearing losses and 9 patients
being answered using a five-point semantic dif- with moderate hearing losses; the same figures
ferential continuum ranging from agree to dis-for the control group were 18and 7 respectively.
agree. Scoring is from 1 to 5 for each question The mean handicap prior to hearing aid fitting
giving a total range from 0 (no handicap), to 120 for the two groups was 74.5 and 77.2 (scores out of
(maximum handicap). The internal reliability 120) for the treatment group and control group
and test-retest variability of the QDS has been respectively. Comparison of these pre-treatment
examined by Tuley et al. (1990) with the conclu- scores using a Mann-Whitney U test showed that
sion that it is a reliable and repeatable scale. they were not significantly different (tiedp value =
The communication course (performed by 0.47). The mode and inter-quartile ranges of the
author CP, Hearing Therapist) was a four-week pre-treatment handicap scores is given in Table 1;
course for groups of 5-7 people and covered the this table also shows the values for the four sub-
following areas: scales of the questionnaire. The average handicap
measured 13 weeks later, after hearing aid fitting,
Session 1: explanation of the anatomy and physi- follow-up and the treatment group having com-
ology of the ear; the nature of hearing impair- pleted the communication course, was 55.8 for the
ment; the effects of hearing impairment in treatment group and and 62.6 for the control group.
different situations. Comparison of these scores using a Mann-Whitney
Session 2: explanation of the benefits and disad- U test showed that they were not significantly dif-
vantages of a hearing aid; hearing aid mainte- ferent (tied p value = 0.1 1). The mode and inter-
nance; adjusting amplification in different quartile ranges of the post-treatment handicap
acoustic environments. Explanation of the scores are given in Table 1; this table also shows the
composition of speech and implications for values for the four subscalesof the questionnaire.
348 Graham J. Beynon et al.

Table 1. Handicap scores (QDS) pre- and post-treatment

Total Family Self Vocational Communication

T C T C T C T C T C

Pre-treatment
Mode 73 80 10 8 10 18 36 39 15.5 16
Inter-quartile range 13 29.25 5 6.5 7 5.5 9 20.5 5 3.25

Post-treatment
Mode 56 63 10 8 8.5 14 22.5 29 9 13
Inter-quartilerange 15 29.75 6 5 7 5.25 14 23 7 5
T = treatment group; C = control group

The change in handicap measured for each
patient was examined for the treatment and con-
trol group separately using a Mann-Whitney U
test. This showed that the handicap measured
after hearing aid fitting and follow-up for the con-
trol group was significantly lower than that mea-
sured prior to fitting (tied p value = 0.005). The
same comparison for the treatment group
showed that the handicap measured after hearing
aid fitting, follow-up and the communication
course was significantly lower to that measured
prior to fitting (tiedp value <0.0001).
The change in handicap before and after treat-
ment was calculated for each patient by subtract-
ing the handicap measured after the 13 week
period from that measured at the hearing aid fit-
ting. This was calculated for the total score and
the 4 subscales. The change in total handicap
score for the two groups was 18.7 for the treat-
ment group and 14.6 for the control group (total
score = 120). Comparison of these changes by a
Mann-Whitney U test showed that the change for
the treatment group was significantly larger than
that for the control group (tiedp-value = 0.014).
A histogram of these changes in total handicap is
shown in Figure 1.
The change in handicap for the four subscales
was compared between the treatment group and
control group using a Mann-Whitney U test. The
vocational and communication subscales showed
significantly larger change in the treatment group
compared with the control group (tied p-value
= 0.019 and 0.037 respectively). N o significant
difference between the two groups was seen for

0 Treatment group
W Control group

Y
v)
C
0)
*
.I

m
a
u
0
&
0)
n
5
z

OS 3-10 1015 ISZJ 20.2s 2S.Y) %IS 3 W

Change in total handicap

Fig. 1. Change in QDS score for treatment and control groups
 Communicationcourse for hearing aid users
Table 2. Change in handicap scores (QDS)
Total Family
T C T C
Mode 17.5 14 0 0
Inter-quartilerange 9 4.5 1 2
T = treatment group; C = control group
the family and self subscales (tied p value = 0.56
and 0.11 respectively). The actual changes in the
subscales before and after treatment is shown in
Table 2.
The affect of age was analysed by examining the
correlation between the change in the total handi-
cap score and age for the two groups. For both the
treatment and the control group no significantcor-
relation between these variables was seen (corre-
lation coefficients were 0.06 and 0.16 for the
treatment and control group respectively).
The effect of hearing loss was examined by
comparing the change in handicap for the control
and treatment groups separately. Comparisons
between mild and moderate hearing losses were
made using the Mann-Whitney U test and
showed no significant difference in the change in
handicap for the different classification of hear-
ing loss for either the control group or the treat-
ment group (tied p value = 0.95 and 0.47
respectively).
Discussion
This study evaluated the efficacy of a communi-
cation course by means of a randomized, con-
trolled trial. It can be seen that both the patients
in the control group and the treatment group had
a statistically significant reduction in reported
handicap over the 13week period. This reduction
in handicap for the control group indicates that
rehabilitation in the form of hearing aid fitting
and and a follow-up appointment does signifi-
cantly reduce hearing handicap; this finding has
been demonstrated in several studies (Newman
and Weinstein, 1988;Abrams etal., 1992; Mulrow
et al., 1992). However, comparing the change in
handicap for the two groups showed that the
reduction in handicap for the treatment group
was significantly greater than that for the control
group. Thus, while handicap was reduced for
both groups it was reduced by a greater amount
for the group that had additional rehabilitation in
the form of the communication course.
349
Self Vocational Communication
T C T C T C
2 2 10 6 5.5 4
3 2.25 I 7 3 4.25
Examination of the four subscales of the QDS
indicates the areas in which the communication
course reduced handicap beyond that of the
hearing aid fitting itself. The reduction in handi-
cap for the communication and vocational
subscales was significantly greater for the treat-
ment group. However for the self and family
subscales the reduction was no different between
the two groups. It may be inferred, therefore, that
the components of the communication course
influence patients in these first two areas but not
in the later two. Revision of the content of the
course, such that views of oneself as a hearing
impaired person, and the relationships with ones
family are discussed, may be of benefit. It may of
course also be that these areas are harder to reha-
bilitate people in than in general communication
and socialhocational functioning.
The analysis did not include those patients
dropped from the study for failing to attend the
requisite three sessions as we wished to investi-
gate the change in handicap for only those who
had undergone the treatment. It must be recog-
nized that patients who fail to complete a com-
munication course may well do so due to being
dissatisfied with it, and hence have a poor out-
come. (In this case the reasons given by patients
were either lack of time or ill health.) It is usual to
examine the outcome for this type of study on the
basis of intention to treat; that is, including all
those assigned to the treatment group even if
they fail to complete the treatment. This is not
possible in the present study due to lack of data
on those who failed to complete the treatment.
The possible effect these patients had on the out-
come, however, can be analysed by assigning a
hypothetical outcome handicap score to them. If
it is assumed that they would on average have had
the same decrease in handicap as other members
of the treatment group their post-treatment
handicap score can calculated by subtracting the
average handicap decrease observed for the
treatment group. This would increase the
350 Graham J. Beynon et al.
significance of the difference in handicap change
between the treatment and control group (Mann-
Whitney U test, tiedp value = 0.004). However, if
it is assumed that the communication course was
of no benefit to these patients then their handicap
reduction should on average be the same as the
control group. If their post-treatment score is cal-
culated by subtracting the average reduction in
handicap for the control group, this gives a worst
case scenario. This will reduce the significance of
the difference between the treatment and control
group but it still remains statistically significant
(Mann-Whitney U test, tied p-value = 0.019).
Therefore, it can reasonably be estimated that
the patients who failed to complete the communi-
cation course did not affect the significance of the
difference between the control group and treat-
ment group.
The present study adds to the evidence that a
communication course does significantly reduce
hearing handicap compared to hearing aid fitting
alone. Clearly the questionnaire used to attempt
to measure handicap will influence the outcome
of any study. However, the efficacy of communi-
cation courses has now been demonstrated in
three controlled trials: each used a different ques-
tionnaire to measure self-perceived handicap
(Smaldino and Smaldino, 1988; Abrams et al.,
1992; present study). The common feature of
these studies is that they were performed in
groups and involved little formal auditory train-
ing; neither the present study not that of Abrams
et al. (1992) contained any auditory training; that
by Smaldino and Smaldino (1988) had one of four
sessions focusing on auditory training. It may be,
then, that courses which use a broad range of
techniques, focus on solving difficulties in partic-
ular situations and allow group discussion of cop-
ing with a hearing loss, may prove more
beneficial than those only utilizing one auditory
training technique. Which components of such a
communication are responsible for the reduction
in handicap and which components may be omit-
ted is a subject for further research.
The main criticism of this type of study is that
the observed reduction in handicap in the group
undergoing additional rehabilitation is due to a
placebo effect. The reported benefit could simply
be due to the larger amount of contact time the
patient has received rather than the content of the
communication course itself. This same criticism
is true of the studies mentioned above and is
extremely difficult to avoid as a suitable placebo
therapy that involves the same amount of patient
contact time as a communication course is hard to
conceive. There are two issues involved in this
criticism. First, the aim of this study is to examine
whether a communication course reduces handi-
cap compared to hearing aid fitting only, rather
than examining one rehabilitation technique ver-
sus another. Therefore, one group having more
contact time than the other is an innate part of the
study and no defence need be made for this. The
second and more difficult area is whether the ben-
efit reported by the treatment group is simply due
to the patient feeling that more time and effort
has been put into their treatment. The use of a
standardized questionnaire is the crucial element
in avoiding this halo effect as much as possible.
The questionnaire focuses attention on actual
real life situations and difficulties rather than
some global assessment of benefit (e.g. Do you
feel your hearing problems have decreased?) or,
even worse, an assessment of how beneficial
patients felt their therapy was (e.g. Do you feel
the communication course has been beneficial?).
These later alternatives are clearly open to a
halo effect due to greater contact time. There-
fore, while this criticism cannot be completely
refuted there is good evidence for the communi-
cation course having a direct effect on hearing
handicap rather than any feel good factor due to
receiving a large amount of therapy.
This study evaluated the benefit of a communi-
cation course on first time hearing aid wearers.
These findings would suggest that first time hear-
ing aid wearers would benefit from inclusion in a
communication course. It is unlikely that many
departments have the resources for such a service
and therefore having established the efficacy of
such courses identification of those patients who
would benefit the most is required. This study did
not find any trends for the reduction in handicap
to vary with either age or severity of hearing loss.
However, the study only included patients up to
the age of 80, and with hearing losses that were
either mild or moderate; therefore further
research in these areas is required.
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