A Randomized Controlled Trial

J Am Acad Audiol 22:274–285 (2011)

Rehabilitative Online Education versus Internet Discussion Group for Hearing Aid Users: A Randomized Controlled Trial DOI: 10.3766/jaaa.22.5.4 Elisabet Thoreń*† Monica Svensson‡ Anna To¨rnqvist‡ Gerhard Andersson§**†† Per Carlbring§§ Thomas Lunner*†§

Abstract Background: By using the Internet in the audiological rehabilitation process, it might be possible in a cost-effective way to include additional rehabilitation components by informing and guiding hearing aid users about such topics as communication strategies, hearing tactics, and how to handle hearing aids. Purpose: To evaluate the effectiveness of an online education program for adult experienced hearing aid users including professional guidance by an audiologist and compare it with the effects of participation in an online discussion forum without any professional contact. Research Design: A randomized controlled study with two groups of participants. Repeated measures at prestudy, immediate follow-up, and a 6 mo follow-up. Study Sample: Fifty-nine experienced hearing aid users participated in the study, ranging in age from 24 to 84 yr (mean 63.5 yr). Intervention: The intervention group (N 5 29) underwent a five-week rehabilitative online education in which activities for each week included information, tasks, and assignments, and contact with a professional audiologist was included. The participants in the control group (N 5 30) were referred to an online discussion forum without any audiologist contact. Data Collection and Analysis: A set of questionnaires administered online were used as outcome measures: (1) Hearing Handicap Inventory for the Elderly, (2) International Outcome Inventory for Hearing Aids, (3) Satisfaction with Amplification in Daily Life, and (4) Hospital Anxiety and Depression Scale. Results: Significant improvements measured by the Hearing Handicap Inventory for the Elderly were found in both groups of participants, and the effects were maintained at the 6 mo follow-up. The results on the Hospital Anxiety and Depression Scale showed that the participants in the intervention group showed reduced symptoms of depression immediately/6 mo after the intervention. At the 6 mo follow-up participants in the control group reported fewer symptoms of anxiety than they did before the intervention started. Conclusions: This study provides preliminary evidence that the Internet can be used to deliver education to experienced hearing aid users who report residual hearing problems such that their problems are reduced by the intervention. The study also suggests that online discussion forums could be used in rehabilitation. A combination of online professional supervised education and online informal discussions could be a promising rehabilitation tool.

*Department of Clinical and Experimental Medicine, Linko¨ping University; †Research Centre Eriksholm, Oticon A/S; ‡Department of Clinical Sciences, Logopedics, Phoniatrics, Audiology, Lund University; §Swedish Institute for Disability Research, Linko¨ping and O¨rebro University; **Department of Behavioural Sciences and Learning, Linko¨ping University; ††Department of Clinical Neuroscience, Karolinska Institutet; §§Department of Psychology, Umea˚ University The Oticon Foundation and the Swedish Hard of Hearing Association (HRF) are acknowledged for funding this study.

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Rehabilitative Online Education versus Discussion Group/Thoreń et al

Key Words: Counseling, duty to recontact, hearing loss, Internet, outcome assessment, rehabilitation of hearing impaired Abbreviations: HADS 5 Hospital Anxiety and Depression Scale; HADS-A 5 Hospital Anxiety and Depression Scale, Anxiety; HADS-D 5 Hospital Anxiety and Depression Scale, Depression; HHIE 5 Hearing Handicap Inventory for the Elderly; HHIE-E 5 Hearing Handicap Inventory for the Elderly, Emotional Consequences; HHIE-S 5 Hearing Handicap Inventory for the Elderly, Social Consequences; IOI-HA 5 International Outcome Inventory for Hearing Aids; LACE 5 Listening and Communication Enhancement; SADL 5 Satisfaction with Amplification in Daily Life; SADL-SC 5 Satisfaction with Amplification in Daily Life, Service and Cost; T0 5 data collected before the intervention; T1 5 data collected immediately after the intervention was finished; T2 5 data collected at the 6 mo follow-up

INTRODUCTION

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udiological rehabilitation consists of many elements, and several authors have suggested that psychosocial factors should be included in addition to instrumentation and test procedures (e.g., Goldstein and Stephens, 1981; Stephens, 1996; Chisolm et al, 2004). Despite this long-standing suggestion, many hearing impaired persons are not offered any additional rehabilitation once the hearing aids have been fitted, and contributing factors can, for example, be immobility and the difficulty of scheduling the clinical resources of educational and rehabilitative sessions. Patients in health care are increasingly using the Internet to gather information about their health problems (Hesse et al, 2005), both before and after medical consultations. Results from Barak and Sadovsky (2008) indicated that when comparing Internet use in a group of hearing impaired adolescents with a group of normal hearing adolescents, the hearing impaired adolescents tended to use the Internet more intensively and were more willing to use the Internet when searching for information or as a medium for communicating with others. Recent research has shown positive effects when combining hearing aids with additional rehabilitation (Abrams et al, 2002; Kramer et al, 2005; Hickson et al, 2006). By using the Internet it would be possible to inform and guide people with hearing impairment about such topics as communication strategies, hearing tactics, and how to handle hearing aids in a cost-effective way, without the inconvenience for the patient of traveling to a location away from home. If online rehabilitation is effective, it should be possible to measure improvements in the hearing aid users being less limited by their hearing loss. Being less limited by hearing loss refers to an outcome measure of reduced activity limitation and reduced participation restriction as it is defined by the World Health Organization (2001). Studies in chronic disease areas such as asthma have shown that an online educational program helped the patients to improve their knowledge about asthma and thereby take more responsibility for their condition (Hartmann et al, 2007). Studies in other research fields such as tinnitus and mood and anxiety disorders have

shown promising results when using the Internet as a way of delivering psychological treatment in randomized, controlled intervention studies (Andersson et al, 2002; Carlbring and Andersson, 2006; Andersson, 2009). In some studies, the participants in the control group were referred to an online discussion forum so participants in both groups had some Internet activity. It was concluded that when the participants were interacting only with each other (discussion forum), they did not improve to the same extent as the participants who had contact with professionals via the Internet (Andersson, 2009). The use of computerized home training programs for hearing aid users has been evaluated, for example, Listening and Communication Enhancement (LACE; Sweetow and Henderson Sabes, 2006; Henderson Sabes and Sweetow, 2007). In LACE, the focus is on the subjects’ cognitive skills, communication strategies, and understanding of rapid speech in a home-based training program with interactive and adaptive tasks on the computer. During the program the subjects send the results from the training via the Internet to their audiologist for further discussions in the clinic. Results indicate that nearly 80% of the subjects improved to some degree on both subjective and objective outcome measures by using LACE. The researchers of LACE conclude that the subjects may have greater self-motivation because the program is home based and thereby time-effective. In a study by Laplante-Le´vesque et al (2006), contact via e-mail between the hearing impaired and audiologist was used in the rehabilitation process. Three first-time users of hearing aids received support via e-mail during their first month with hearing aids. The aim of the study was to evaluate how increased communication between the audiologist and the client affected the use of the hearing aids. The conclusion of the study was that e-mail communication with an audiologist is useful in the audiological rehabilitation process to share experiences and to provide audiological counseling. Study Objectives The aim of this study was to evaluate an online education program for adult experienced hearing aid users


Journal of the American Academy of Audiology/Volume 22, Number 5, 2011

including professional guidance by an audiologist. It was hypothesized that the education would reduce factors such as activity limitation and participation restrictions. Hence, the first hypothesis was that participants in an online education would perceive a significant improvement of their activity limitations and participation restrictions, while participants in a control group, with online interaction with peers, would not. Further, the second hypothesis was that after finishing the education the participants in the intervention group would be significantly more satisfied hearing aid users than participants in the control group. The third hypothesis was that taking part in the online education would have significantly more positive consequences regarding psychosocial well-being than being part of a control group. Finally, the fourth hypothesis was that the positive effect of taking part in an online education would be maintained 6 mo after the study was finished, while participants in the control group could not achieve any measureable differences

after 6 mo when comparing data before the study started with data collected after 6 mo. METHOD

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he design of the randomized controlled study, the analysis of the results, and the interpretation of the findings followed the CONsolidated Standards of Reporting Trials (CONSORT statement; Altman et al, 2001). This means that a checklist and a flowchart (Fig. 1) of the participants’ progress through the study were followed to generate transparent reporting and thereby aid the readers in understanding and interpreting the results. Recruitment and Procedure The participants were recruited through advertisements in Swedish national daily newspapers where they were referred to the study Web site. Figure 1

Figure 1. Flowchart of recruitment and participation procedure. *Included in analysis on intention-to-treat basis (see text).



presents a flowchart of the recruitment and study procedure. The study Web site provided general information about the study and instructions on how to proceed for participation in the study. In the information text about the study it was highlighted that the participants should be prepared to allocate at least 1.5 hr each week for studying and completion of the assignments. First of all, potential participants were instructed to complete screening questions on the study Web site to ensure that they fulfilled the inclusion criteria. The inclusion criteria were that the participants (1) should have a hearing impairment with subjective, significant communication difficulties, (2) should have been using hearing aids for at least 1 yr, (3) were at least 18 yr old, (4) had Swedish as a first language, (5) had access to a computer and the Internet. To ensure that participants with difficulties that were not dealt with in the online education were not admitted into the study, the following exclusion criteria were defined as (1) not being able to have a conversation by telephone, (2) severe tinnitus, or (3) Meńie`re’s disease diagnosis. Further on, the potential participants had to answer online versions of four standardized questionnaires (see below for a description of the questionnaires) and they completed a set of background questions requesting their e-mail address, their home address (so the audiologist could send the course literature to them), and information on their age, gender, and education. As this is a “proof of concept” study of rehabilitative online education, we wished to ensure that any positive effects would be detectable. Therefore an extra inclusion criterion was defined to ensure that the included participants had substantial residual hearing problems before entering the study. According to Weinstein and Ventry (1983) there is a correlation between a moderate hearing loss (a pure tone average of 41–55 dB) and a self-rated score of at least 24 on the Hearing Handicap Inventory for the Elderly (HHIE). Therefore we defined that a score of 20 or more on the HHIE should be an appropriate threshold value for a significant number of communication problems. A total of 63 participants fulfilled the inclusion criteria for the study and had an initial HHIE score over 20. Before the study started, these 63 potential participants were interviewed by telephone to ensure that they were willing and able to participate in the study. On the basis of the telephone interview an additional four potential participants were excluded. Reasons for exclusion were either apparent lack of interest (N 5 2) or not being able to manage the telephone interview (exclusion criterion 1 above, N 5 2). The participants (N 5 59) were randomized by an independent person (not involved in the study or recruitment) to either participate in the intervention group (I-group) or in the control group (C-group). The

participants in the I-group attended a five-week online education including weekly assessments and interaction with an audiologist. The participants in the Cgroup attended a discussion forum with weekly topics to discuss with each other but with no interaction with an audiologist. The participants took part in the study on a voluntary basis and were not financially compensated for their time. The study protocol was approved by the medical ethics committee in Linko¨ping, Sweden, and written informed consent was obtained from the participants. Participants Fifty-nine hearing impaired participants (29 women and 30 men) were included in the study. Their ages ranged from 24 to 84 yr (M 5 63.5 yr; SD 5 13.3 yr). All participants were requested to contact their hearing clinic and ask for their latest audiogram, which they sent to the audiologist in this study. There were two objectives with collecting the audiograms. The first was to get the hearing data of all participants. The second had a pedagogical purpose, to sketch a speech area in the audiograms and then send them back to the participants so they could learn more about their own hearing loss as a part of the first learning task. The participants had on average a hearing loss corresponding to a moderate, typical sloping presbyacusis hearing loss. The pure tone average of the better ear at the four frequencies 500, 1000, 2000, and 4000 Hz was on average 52 dB HL (SD 5 25 dB HL; see Fig. 2). Ninety percent of the participants were using hearing aids bilaterally; however, that was not a requirement to be included in the study. The remaining 10% were using amplification monaurally. All participants had been using hearing aids for at least 1 yr, and almost half (42%) had been using them for more than 10 yr. The majority (67%) of the participants had an education equivalent to university level. The I- and C-groups were not significantly different in terms of degree of hearing loss, age, time of hearing aid experience, or educational level. Study Outcomes Four standardized questionnaires were chosen as the outcome measures of perceived hearing aid benefit, satisfaction with hearing aids, perceived activity limitation, and participation restriction. The chosen questionnaires have been shown to be reliable and to have good ¨ berg et al, 2007, 2009) when internal consistency (O used in a Swedish population. The participants had to complete all questionnaires before the educational program started (T0), immediately after the study was finished (T1), and at the 6 mo follow-up (T2) (see flowchart in Fig. 1). All outcome measures were administered



The Satisfaction with Amplification in Daily Life (SADL; Cox and Alexander, 1999, 2001) is a questionnaire of 15 items that measures benefit and positive effects of the hearing aids on a seven-point scale. The questionnaire is divided into four subscales measuring personal image (PI), positive effect (PE), negative feature (NF), and service and cost (SC). Higher scores indicate greater satisfaction and benefit from hearing aids, which were the factors explored in the second hypothesis. Also, the 14-item Hospital Anxiety and Depression Scale (HADS; Zigmond and Snaith, 1983) was included as a secondary outcome measure. This is a questionnaire that measures anxiety and depression of the respondent during the week immediately prior to administration. The questionnaire can be divided into two subscales with seven questions in each, anxiety (HADS-A) and depression (HADS-D). Each item has four possible responses (score 0–3) with a higher score indicating more symptoms of anxiety and depression. The third hypothesis of this study explored psychosocial well-being, and thereby the HADS questionnaire was linked to the third hypothesis of this study. Intervention Figure 2. Average (SD) hearing loss for the participants (dB HL). Right ear is marked with circles and left ear with crosses.

Rehabilitative Online Education—Intervention Group

using the Internet (Andersson et al, 2003; Carlbring et al, 2007). The HHIE (Ventry and Weinstein, 1982; Lichtenstein et al, 1988) was defined as the primary outcome measure. It contains 25 items and generates two subscales; 13 questions are designed to catch emotional consequences of the hearing aid users (HHIE-E), and 12 questions are designed to catch the social and situational consequences of being a hearing aid user (HHIE-S). For each item there are three potential responses: yes (4 points), sometimes (2), or no (0). A higher score corresponds to more perceived activity limitation and participation restriction, which were the factors explored in the first hypothesis of this study. The other three questionnaires were defined as secondary outcome measures. The International Outcome Inventory for Hearing Aids (IOI-HA) is a seven-item questionnaire measuring benefit of hearing aids (Cox et al, 2000, 2002, 2003). Each item focuses on a different topic: (1) daily use, (2) benefit, (3) residual activity limitation, (4) satisfaction, (5) residual participation restriction, (6) impact on others, and (7) quality of life. Each item has five potential responses, which range from the worst to the best outcome. A higher score on this questionnaire indicates better outcomes with hearing aids, and that was the factor explored in the second hypothesis of this study.

The rehabilitative online education was based on material from the book Fading Sounds (Elberling and Worsøe, 2005). The setup of the online education application, in terms of the flow of weekly tasks and interaction with an audiologist, was inspired by studies of tinnitus and mood and anxiety disorders in adjacent research fields (Andersson et al, 2002; Carlbring and Andersson, 2006; Andersson, 2009). The material (presented in Swedish) consisted of 82 pages of text divided into five chapters that were used as weekly modules in this intervention: (1) introduction and hearing anatomy, (2) measuring hearing loss, (3) five dimensions of hearing, (4) hearing aids, (5) coping strategies and future goals. Each module included information and four to six different tasks and assignments that were related to the book (see Appendix A, for example). The participants were expected to spend about 1.5 hr each week on reading the designated chapters in the book, performing the tasks, and writing about their experiences. They sent their written work to the audiologist, who gave e-mail feedback and advice to the participants within five working days. Each module ended with a short quiz of five questions on the content of the week’s module. The participants got immediate responses, and when all questions in the quiz had been correctly answered, the participant gained access to the next education module within 24 h.



Each module was available on the Web site in HTML (hypertext mark up language) format. The Web site was built by Java Server Pages (JSP) programming and a MySQL database. The participants in the I-group received a hard copy of the course book (Elberling and Worsøe, 2005) by mail, but they could also read each chapter on the screen or print them as portable document format documents (PDFs) from the study’s homepage.

Windeler, 2001; Gadbury et al, 2003; Mallinckrodt et al, 2003). Confidence intervals and three-way mixed model analysis of variance (ANOVA) were carried out with the software package STATISTICA version 7 (2008). Post hoc tests, throughout this paper, were based on Bonferroni correction. However, the HADS data were found to be skewed. Therefore the I-group and C-group were separately analyzed with the nonparametric Wilcoxon matched pair test.

Online Discussion Forum—Control Group RESULTS The participants in the C-group were referred to a discussion forum built on the open source platform phpbb.com. The method of using an online discussion group without professional interaction with an audiologist was inspired by studies in adjacent research fields like tinnitus and mood and anxiety disorders (Andersson, 2009). Each week they were assigned a new topic to discuss. The five topics were (1) Tell us about your hearing problems, how do they affect you? (2) How do your hearing problems affect your significant others? (3) Tell us about an ordinary day with your hearing loss, (4) Some people argue that society nowadays demands more from people’s hearing than before, what do you think about that? (5) Describe in what way your hearing loss limits you. All activities in the C-group were closely monitored, with the possibility of deleting inappropriate postings. However, this never occurred. There were no requirements stipulated to the participants in terms of how active they should be in the discussion forum. The discussion forum was closed after the 5 wk period. The participants received a hard copy of the course book (Elberling and Worsøe, 2005) by mail when the study was ended. 6 mo Follow-Up The participants in the I-group and the C-group were contacted by e-mail, mail, or telephone and asked to fill in the questionnaires (HHIE, SADL, IOI-HA, and HADS) again online 6 mo after the study had ended.

M

easures at T1 were completed by 25 participants in the I-group and 26 in the C-group (results are shown in Table 1). The main reason given for leaving the study was that the study was perceived as too demanding and that there were some technical problems using the computer, Internet, and/or the login system where two participants did not fully agree on our high level of securing the personal information. The rates of withdrawal did not differ significantly between the I-group and the C-group. The rate of withdrawal from the study was 14% (8 of 59). At T2 all except another three participants completed the online assignments. The main reasons for not completing the assignments were computerrelated problems or being on holiday. All participants in the I-group that fulfilled the study were active and wrote each week answers on the assignments to their audiologist and answered the weekly online quizzes. Analysis of the participants’ activity in the C-group showed that on average there were 18 (SD 2.6) contributions posted and 27 (SD 15.1) replies written each week. The tendency was more activity in the beginning of the study than at the end. However, is it worth mentioning that it was only the written activity that could be registered, which means that we have no statistics of how much the participants were reading each other’s dialogue. The typical conversation regarded technical issues with the hearing aids or assistive listening devices and tip-offs of specific solutions to overcome different problems. Outcomes on Self-Report Measures

Analysis of Outcome Measures Primary Outcome Measure, HHIE Data from three measurement time-points have been used in the analysis; T0 corresponding to prestudy data, T1 corresponding to data collected immediately after the intervention was finished, and T2 corresponding to the 6 mo follow-up (Table 1). All data for those participants who did not complete the study have been treated on an “intention-to-treat” basis. The method of “last observation carried forward” has been used, which means, for example, that missing data at T1 were replaced with T0 data (Unnebrink and

Analyses of variance with a 2 3 3 design (one group factor and two repeated-measures factors) indicated significant within-group effect (W) for the primary outcome measure of the total HHIE score (F2,114 5 11.8; p , 0.001). The results from post hoc analysis showed a significant difference from T0 to T1 ( p , 0.001) and from T0 to T2 ( p , 0.05). This within-group effect indicates that participants in both groups decreased their subjective participation restriction and activity limitation



Table 1. Means and SDs for Questionnaires at T0, T1, and T2 Questionnaire

T0

T1

T2

T0–T1–T2

T0–T1

T0–T2

T1–T2

Mean (SD)

Mean (SD)

Mean (SD)

F-value

Post hoc

Post hoc

Post hoc

26.2 (6.4) 27.7 (5.5)

22.4 (9.3) 25.5 (5.8)

24.9 (9.0) 24.5 (7.0)

W: 11.79*** I: 3,68*

I-group C-group

13.3 (3.1) 13.8 (3.0)

11.2 (4.6) 13.0 (2.9)

12.7 (4.0) 12.5 (3.6)

W: 9.40*** I: 4.36*

I-group C-group

12.9 (4.2) 13.9 (3.7)

11.2 (5.2) 12.5 (3.8)

12.2 (5.4) 12.0 (4.4)

W: 8.01**

HHIE (range 0–100) Total I-group C-group Social

Emotional

SADL (range 0–105) Total I-group C-group PI I-group C-group PE I-group C-group SC I-group C-group NF

I-group C-group

IOI-HA (range 0–35) Total I-group C-group Item 1 I-group C-group Item 2 I-group C-group Item 3 I-group C-group Item 4 I-group C-group Item 5 I-group C-group Item 6 I-group C-group Item 7 I-group C-group HADS (range 0–42) Total I-group C-group

4.3 4.3 4.3 4.2 5.0 5.2 3.6 3.2

(0.5) (0.7) (0.8) (0.8) (1.0) (1.4) (0.9) (1.0)

3.4 (1.2) 3.1 (1.2)

24.3 24.4 4.0 4.4 3.7 3.8 2.6 2.3 4.2 3.9 3.4 3.3 3.3 3.3 3.2 3.5

(4.9) (5.9) (1.2) (1.2) (1.0) (1.2) (0.9) (1.0) (1.0) (1.2) (1.0) (1.0) (1.0) (1.0) (1.1) (1.3)

4.3 4.2 4.2 4.4 5.1 5.1 3.6 3.4

(0.6) (0.7) (0.9) (0.8) (1.1) (1.4) (0.8) (1.0)

3.4 (1.4) 3.2 (1.2)

25.5 25.3 4.0 4.3 3.8 3.9 2.6 2.4 4.1 4.3 3.9 3.4 3.6 3.3 3.5 3.7

(5.3) (5.9) (1.1) (1.3) (1.1) (1.3) (1.1) (0.9) (1.1) (1.3) (0.9) (1.1) (1.1) (1.0) (0.9) (1.1)

4.1 4.3 4.1 4.4 5.0 5.2 3.1 3.3

(0.6) (0.5) (0.9) (0.8) (1.3) (1.2) (0.9) (1.1)

*** I-group***, C-group ns *** I-group***, C-group ns ***

** C-group**, I-group ns * I-group*, C-group ns **

I: 3.21*

W: 3.42* I: 4.28*

I-group*, C-group ns

* I-group*, C-group ns

3.3 (1.3) 3.3 (1.2)

24.1 25.4 3.9 4.4 3.7 3.8 2.5 2.5 3.9 4.2 3.6 3.6 3.4 3.5 3.2 3.5

(5.1) (4.7) (1.3) (1.2) (1.2) (1.1) (0.9) (1.0) (1.2) (1.1) (1.0) (1.0) (1.1) (0.8) (1.1) (1.1)

7.9 (6.5) 8.1 (6.1)

6.8 (6.2) 7.8 (6.9)

8.2 (6.9) 7.6 (5.4)

Anxiety

I-group C-group

3.7 (3.7) 4.1 (3.5)

3.8 (4.2) 3.5 (3.5)

4.4 (4.1) 3.6 (3.2)

Depression

I-group C-group

4.2 (3.3) 4.0 (3.0)

3.0 (2.5) 4.2 (3.9)

3.8 (3.5) 4.0 (2.8)

I-group* Wilcoxon, C-group ns I-group* Wilcoxon, C-group ns, I-group** Wilcoxon, C-group ns

Note: F-values show the within-group effects (W) and interaction effects (I) between groups and types of intervention. Significant effects were post hoc analyzed. N 5 30/29 in I-group/C-group. *p , .05 **p , .01 ***p , .001



significantly at T1 and that the improvements were maintained at T2. A significant interaction effect (I) was also detected (F2,114 5 3.7; p , 0.05). The post hoc analysis showed that the I-group decreased their scores significantly from T0 to T1 ( p , 0.001) but not from T0 to T2 (p . 0.05), whereas the C-group decreased their scores significantly from T0 to T2 ( p , 0.01) but not from T0 to T1 ( p , 0.05). The interaction effect suggests that the I-group significantly decreased their subjective participation restriction and activity limitation at T1 but the results were not maintained at T2, while the C-group did not decrease their subjective participation restriction and activity limitation significantly at T1 but showed a decrease at T2. In the subscale HHIE-S a within-group effect (W) was detected (F2,114 5 9.4; p , 0.001). The results from the post hoc analysis showed a significant difference from T0 to T1 ( p , 0.001) and from T0 to T2 ( p , 0.05). This within-group effect indicates that participants in both groups decreased their scores in the social domain of subjective participation restriction and activity limitation significantly at T1 and that the improvements were maintained at T2. Further on, a significant interaction effect (I) was detected (F2,114 5 4.4; p , 0.05). The post hoc analysis showed that the interaction effect could be explained by a significant difference in the I-group from T0 to T1 ( p , 0.001) and from T1 to T2 ( p , 0.05). The interaction effect indicates that the I-group significantly improved their results in the social domain of subjective participation restriction and activity limitation at T1 and then significantly worsened the results at T2, while the C-group did not score significantly different at the three occasions in the HHIE-S subscale. In the HHIE-E subscale a within-group (W) effect (F2,114 5 8.0; p , 0.001) was found. The post hoc analysis showed a significant difference from T0 to T1 ( p , 0.001) and from T0 to T2 ( p , 0.01). This within-group effect indicates that participants in both groups improved in the emotional domain of subjective participation restriction and activity limitation significantly at T1 and that the improvements were maintained at T2. No significant interaction effects were detected, which indicates that there were no differences between the groups in terms of improvements at T1 and T2 in the emotional subscale of HHIE. Secondary Outcome Measures, SADL, IOI-HA, HADS

nificant within-group effect (W) was measurable over time (F2,114 5 3.4; p , 0.05). The post hoc analysis showed a significant decrease of hearing aid satisfaction between T1 and T2 ( p , 0.05). An interaction effect (I) was detected (F2,114 5 4.3; p , 0.05) in SADL-SC. The post hoc analysis showed a significant decrease of the SADL-SC score in the I-group between T0 and T2 ( p , 0.01) and between T1 and T2 ( p , 0.01). Results from the IOI-HA did not show any significant results in the total score or in the items separately. On the psychosocial outcome measure (HADS), a significant effect was found in the domain measuring depression for the I-group (Wilcoxon, T 5 38, Z 5 2.5, p , 0.01) between T0 and T1, indicating that the I-group HADS-D scores were lowered and therefore improved. The analyses of the C-group did not show a significant difference between T0 and T1 (Wilcoxon, T 5 87, Z 5 0.32, p 5 0.75), indicating that the HADS-D scores of C-group did not improve. Further on, a significant effect was found in the domain measuring anxiety in the Igroup (Wilcoxon, T 5 51, Z 5 2.02, p , 0.05), indicating that the HADS-A scores had worsened from T0 to T2. The analyses of the C-group did not show a significant difference between T0 and T2 (Wilcoxon, T 5 57.5, Z 5 1.21, p 5 0.22), indicating that the HADS-A scores of the C-group did not change. Finally, on the total score of HADS a significant difference was found in the Igroup when comparing ratings from T1 and T2 (Wilcoxon, T 5 47, Z 5 2.2, p , 0.05), indicating that they scored a higher (worse) result at T2 than they did at T1. The analyses of the C-group did not show a significant difference between T1 and T2 (Wilcoxon, ns), indicating that the HADS scores of the C-group did not change. DISCUSSION

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he aim of this study was to evaluate a rehabilitative online education program for adult experienced hearing aid users. It was hypothesized that participants in an online education would perceive a significant decrease of activity limitations and participation restrictions, increase their hearing aid satisfaction, and show positive effects on psychosocial well-being outcome measures, and, finally, that the effects would be maintained 6 mo after the intervention was finished while participants in the C-group would not show any measurable differences in these topics. Outcome Measures

The secondary outcome measures used in the study were SADL, IOI-HA, and HADS. Results from the total score of SADL showed a significant interaction effect (I) over time (F2,114 5 3.2; p , 0.05). The post hoc analysis did not show any significant results in the groups separately at the three occasions. In the subscale measuring service and cost (SC), a sig-

Primary Outcome Measure, HHIE The first hypothesis of this study concerned the between-group effects for those attending an online education (I-group) and those attending the online discussion forum (C-group). It was hypothesized that participants in



the I-group would perceive a significant reduction of their activity limitations and participation restrictions when compared to the participants in the C-group when measured by the primary outcome measure HHIE. The results from our study could partly support the first hypothesis. The results from T1 showed significantly decreased activity limitations and participation restrictions when measured by the online self-report HHIE in both the I-group and the C-group. Thus, both the I- and C-group benefited from participation in this study. When looking at the activity in the C-group we noticed that the participants exposed their problems and solutions to each other in a very friendly and constructive way. The high level of activity and constructive help evident here was not expected due to results from earlier studies that used a discussion forum in the control group (Andersson, 2009). Since the participants in the C-group were exchanging information and experiences in the way they were, it might be more appropriate to name them an active control group or even an intervention in itself. Given that the control group received an active intervention, it is probably not surprising that participants in that group showed improvements on the primary outcome measure, HHIE, since they were actively participating in discussions and could learn from each other. It could be concluded that it is challenging to design the setup of a control group. In this study it was obvious for the participants that the Internet was part of the education and thereby some Internet activity should be involved also in the control group in order to have a credible control condition. The use of HHIE as a primary outcome measure in a context like this is worth considering. Hearing aid fitting interventions can show large pre-post improve¨ berg et al, 2008), ments on HHIE (see, for example, O but the HHIE measurement has been used with varying success when evaluating rehabilitation programs. Abrams et al (1992) showed positive improvements by using HHIE when evaluating counseling in the clinic, while Cherry and Rubinstein (1994) could not see any positive effects in the HHIE scores when using HHIE in a telephone follow-up, neither could Kricos and Holmes (1996) when they used HHIE in a comparison of two different rehabilitation programs with a control group. In this study, our group of participants were used to hearing aids but still experienced problems related to their hearing loss. In future studies it might be more appropriate to have a goal in consideration of how people are using their hearing in different situations instead of focusing on what they cannot hear due to their hearing loss. Secondary Outcome Measures, SADL, IOI-HA, and HADS The second hypothesis in this study was that after finishing an online education program (T1) the partic-

ipants in the I-group would be significantly more satisfied hearing aid users than participants in the C-group. The hypothesis was evaluated by using secondary outcome measures, the online self-reports SADL and IOI-HA. The hypothesis could not be confirmed in this study. The results from the total SADL score indicate that participants in the I-group did not rate their hearing aid satisfaction significant differently after the study (T1) than before (T0). In general, it is noticeable that the participants in this study rated rather low SADL scores when compared with Cox and ¨ berg et al (2007), and there Alexander (1999) and O were only small differences in the score at T0 and T1. Cox and Alexander (1999), when evaluating the SADL, noticed that there were relatively few items in the SC subscale for those not paying for their hearing aids and concluded that the SC subscale may be less valid for nonpaying populations. Since the majority of Swedish hearing aid users only pay a small fee for fitting their hearing aids, it could be argued that the few items in the SADL-SC subscale correspond to less validity for this particular population, and thereby it could be concluded that the results are of minor importance. The results from the IOI-HA did not show any significant differences between T0 and T1. The overall results from IOI-HA were, however, in line with results obtained by Cox and Alexander (2002) when evaluating the hearing aid outcomes in a sample of 172 subjects. The differences in IOI-HA scores between T0 and T1 were not significant but are in line with the findings from Kramer et al (2005), who used the IOI-HA to evaluate a hometraining program for hearing aid users. We could consider using another evaluating tool since our findings could not fully support the second hypothesis about hearing aid satisfaction. The components in the online education could, for example, be evaluated by using a revision of the hearing aid outcome (IOI-AI [International Outcome Inventory—Alternative Intervention]) by rephrasing some questions so they more specifically target how the participants used the different tools in the rehabilitation program. That is what Kramer et al (2005) are suggesting in agreement with Noble (2002). The third hypothesis of this study was that taking part in the online education would have significant positive consequences regarding psychosocial well-being that the control group would not experience. A significant effect was found in the HADS data, indicating that the participants of the I-group had decreased and therefore improved ratings on the depression subscale while the participants of the C-group did not. An interpretation of our results is that psychosocial measures such as HADS are sensitive enough to detect effects of online education including interaction between the subject and the professional audiologist, at least immediately after the intervention.



6 mo Follow-Up The fourth hypothesis of the study was that the findings from the immediate follow-up in the I-group would be maintained 6 mo (T2) after the intervention period. Our study could partly support that hypothesis. The results from the primary outcome measure (HHIE) showed that, 6 mo after the intervention period (T2), participants in general, across groups, still rated their participation restriction and activity limitation significantly lower than they did initially. Further, we could see that the I-group gave their lowest ratings of participation restriction and activity limitation right after the study was finished (T1), whereas 6 mo after the study (T2) the ratings had increased again. This can be a sign of the importance of social interaction and that some form of follow-up could be necessary. In earlier studies (Abrams et al, 2002; Hickson et al, 2007) it has been shown that being part of a peer group can in the long term be as rewarding as getting supervision from the audiological profession. This can explain why participants also in the C-group maintained a reduction of participation restriction and activity limitation, since they got the possibility to discuss hearing-related problems with each other and perhaps resolve some of them in the discussion forum. Furthermore, the participants in the C-group received a hard copy of the course book (Elberling and Worsøe, 2005) when the intervention was finished, and we cannot discount the possibility that reading the book in the time period between T1 and T2 might change a participant’s subjective notion about their hearing problems. Since the results from the secondary outcome measures (SADL and IOI-HA) did not show any changes from T0 to T1 that were significant in the post hoc analysis, no effects were expected at T2. Significant effects were displayed in the last secondary outcome measure, HADS. The effect indicated that the participants of the I-group rated their total score of HADS higher (worse) 6 mo after the study (T2) than they did immediately after the study was finished (T1). Further, the I-group also had worse ratings on the anxiety subscale over the 6 mo period, but the participants of the C-group did not. Therefore, the significant effect on the depression subscale that was shown at T1 was not maintained at T2. Kramer et al (2005), referring to Herth (1998), argue that 6 mo is a short time frame for showing the emotional benefits from this kind of program. That argument could in a way explain parts of our results from the 6 mo follow-up. One way to maintain a stronger effect in the I-group could be to include/continue active communication with a professional audiologist via, for example, more assignments or exercises after the online educa-

tional program so the new knowledge about their hearing and hearing loss has a chance to affect their daily behavior with respect to different problematic communication situations. Future Research There is a need for more research in and further development and evaluation of rehabilitative educational online tools such as the ones described in this paper. We have identified some limitations of the study. The participants were younger and had a higher educational level than the normal population of hearing aid users. Therefore we cannot say that the program described in this article fits all hearing aid users; it could be assumed that it best fits those who like reading and getting information by themselves, and subjects with reading or vision disabilities could have problems with a program like this. On the other hand, the Internet is a very useful medium where a rehabilitation program in the future could be individualized. In the hearing clinic there need to be rehabilitation programs that are useful for all subjects. The program we have evaluated in this study could be seen as complementary to the audiologist’s rehabilitation toolbox. Both interventions showed utility with respect to positive and sustainable outcomes. Some aspects of each intervention appear to affect different complementary aspects of outcome. Thus a combination of both might be more comprehensively effective. For example, consider developing a program with a combination of guidance from professional audiologists and the opportunity to discuss and exchange experiences regarding hearing loss-related problems with hearing impaired peers (Hickson et al, 2007). That means that focus in future studies should be on combining an education that consists of information-based rehabilitation and problem solving exercises with peer discussion. That is also in line with Cummings et al (2002), who argue that we should not choose one way of communicating over the other but integrate communication from online chat rooms with support from the real-world more. Results from this study indicate that there are no technical barriers to combining the two types of intervention. CONCLUSIONS

O

verall, the results from this study showed that it is possible to use online tools in the rehabilitation process for older hearing aid users. The practical setup of using the Internet for interactions with the population in question succeeded, since almost all participants completed the computerized exercises. The two forms of intervention applied here, (1) rehabilitative online education and interaction with professional audiologists and (2) peer group online discussions, both



provide positive rehabilitation effects, though not in entirely similar domains of outcome. It is suggested that combining elements of both approaches may provide a more comprehensive rehabilitation, without losing the benefits of either approach.

Cox R, Hyde M, Gatehouse S, et al. (2000) Optimal outcome measures, research priorities, and international cooperation. Ear Hear 21(4, Suppl.):106S–115S.

Acknowledgments. Thanks to Milijana Lundberg and

Cummings JN, Sproull L, Kiesler SB. (2002) Beyond hearing: where real-world and online support meet. Group Dyn 6(1):78–88.

¨ berg for fruitful discussions before and during the Marie O study, and to Graham Naylor for valuable comments on the manuscript.

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Cox RM, Stephens D, Kramer SE. (2002) Translations of the International Outcome Inventory for Hearing Aids (IOI-HA). Int J Audiol 41:3–26.

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Appendix A. Example of Assignments in the Online Education

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Week 1 This week you are going to learn about, and investigate your hearing system. Please read chapter 1 in the book. The assignments for this week are: 1. Get to know your hearing with and without hearing aids. Rattle your keys, knock on a wooden door, browse through a newspaper, etc. Try to find out which sounds are low frequencies and which are at high frequencies. 2. Are you able to identify where the sounds are coming from? Investigate if there are any differences with or without hearing aids. Ask someone in your family to talk to you from behind while he/she is moving around. Are you able to find where the speaker’s voice is coming from?
