J Am Acad Audiol 12 : 128-141 (2001)
Development of the Three-Clinic
Hearing Aid Selection Profile (HASP)
Gary P. Jacobson*
Craig W. Newman'
David A. Fabryt
Sharon A. Sandridget
Abstract
The Three-Clinic Hearing Aid Selection Profile (HASP) was developed to assess a patient's
beliefs about a number of basic considerations felt to be critical to the hearing aid selection
(HAS) process. These characteristics are felt to be key to the acceptance of amplification
and include motivation, expectations, cost of goods and services, appearance (cosmesis),
attitudes about technology, physical function/limitations, communication needs, and lifestyle.
The results of the first investigation suggest that we have been successful in developing a
40-item metric with adequate internal consistency reliability that assesses the aforementioned characteristics. Second, results of the administration of this tool to a large group of
individuals indicated that (1) age impacted scores on the Technology, Physical Function, and
Communicative Needs subscales; (2) gender impacted scores on the Motivation, Expectation,
Technology, Communicative Needs, and Appearance subscales; (3) previous hearing aid
use affected scores on the Motivation subscale ; (4) level of education impacted scores on
the Physical Function and Lifestyle subscales ; and (5) self-perceived hearing handicap had
an effect on Motivation and Communicative Needs subscale scores . Percentile data collected
from this subject sample are presented as a benchmark against which to evaluate responses
from individual patients . Case studies are presented to illustrate the potential clinical utility
of this device .
Key Words: Amplification, expectations, hearing aid, outcomes measures, satisfaction
Abbreviations : ANOVA = analysis of variance, CIC = completely in the canal, COSI = Client
Oriented Scale of Improvement, DSP = digital signal processing, HAS = hearing aid selection, HASP = Hearing Aid Selection Profile, HHIA = Hearing Handicap Inventory for Adults,
HHIE = Hearing Handicap Inventory for the Elderly
t is a common perception that a successful
hearing aid fitting is, in large part, based
on the ability to narrow the gap between a
patient's expectations of what a hearing aid will
do and what the audiologist knows the hearing
aid can do . That is, the recommendation of a particular hearing aid fitting probably is best
derived as a function of the partnership between
the audiologist and the patient. Given this rela*Division of Audiology, Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health
System, Detroit, Michigan ; (Department of Otolaryngology
and Communicative Disorders, The Cleveland Clinic
Foundation, Cleveland, Ohio ; $Department of Otolaryngology, Mayo Clinic Foundation, Rochester, Minnesota
Reprint requests : Gary P. Jacobson, Division of
Audiology, Henry Ford Hospital, 2799 West Grand Blvd .,
Detroit, MI 48202
128
tionship, the assumption follows that a successful hearing aid fitting occurs when the
patient is empowered in the hearing aid selection (HAS ; also referred to by some as "hearing
aid evaluation") process. This occurs when the
patient is informed fully about the relative benefits of all types of hearing aids that are appropriate for the patient's hearing loss, lifestyle,
physical function, and communication needs,
among other biopsychosocial considerations .
Few patients, however, are capable of understanding all of this information in a short period
of time (i .e ., during the HAS appointment) . A
more likely scenario is that the audiologist uses
his/her professional expertise to counsel the
patient to accept a style and level of hearing aid
technology felt to be most appropriate. It is noteworthy that substantial information exists from
Development of the HASP/Jacobson et al
the many MarkeTrak surveys (Kochkin 1994a,
b, 1997, 1998, 1999) pertinent to why patients
resist, dislike, or reject amplification . Although
these investigations have provided information
about group characteristics of hearing aid wearers and nonwearers, the information has not
been used prospectively to assess each patient's
views about these key characteristics prior to the
audiologist's recommendation of a particular
hearing aid . It is likely that, given this information, the number and types of possible hearing aid fittings would converge on an "ideal
fitting" based on the audiologist's expertise and
the patient's prefitting perceptions and needs .
In this regard, there are currently no assessment tools to assist the audiologist in the selection of the most appropriate hearing aid from the
patient's point of view. That is, in an hour or less,
an audiologist must effectively counsel a patient
regarding all types of available amplification
options, ascertain patient's wants and needs,
recommend specific devices, and take earmold
impressions . This process requires that the
patient understand and process highly technical information that is presented at a rapid rate
in a rather limited amount of time . Because of
this time limitation, clinicians are often forced
to make assumptions regarding a patient's attitudes toward cost, cosmetics, and performance
as they relate to hearing aids . Although experienced clinicians may develop specific expertise
or techniques for acquiring this information
from patients during the HAS appointment, it
remains a time-consuming and cumbersome
process .
To this end, the general goal of this series
of investigations was to develop a standardized
measure to be administered prior to the HAS
appointment . The measure would yield, in a
time-efficient manner, information regarding a
patient's perspectives in key areas pertinent to
the selection of a hearing aid . In this way, the
audiologist could spend his or her limited clinical time providing more intensive counseling
about such issues as realistic expectations and
communication strategies . More specifically, the
aims of this study were to (1) develop a simple
and standardized device that might be helpful
in constraining the field of hearing aid choices
based on the individual needs of a given patient
and (2) evaluate how patient characteristics (e .g .,
age, gender, previous hearing aid use, magnitude
of hearing handicap, and educational level) affect
responses to items comprising this device . The
metric described in the following two investigations, namely, the Three-Clinic Hearing Aid
Selection Profile (HASP), was developed by
investigators at the Henry Ford Health System, the Cleveland Clinic Foundation, and the
Mayo Clinic .
INVESTIGATION 1:
DEVELOPMENT OF THE HASP
Method
Subjects
Participants were 130 adults seen for HAS
appointments at the three clinics. There were 72
(55%) males and 58 (45%) females. The average
age of this sample was 64 .2 years (SD = 14 .5
years, range = 14-90 years) .
Test Development
The initial set of 70 items comprising the
alpha version of the HASP was generated based
on the collective experience of the investigators
with hearing aid patients and/or information
regarding consumer acceptance of hearing aids
from the MarkeTrak investigations (Kochkin,
1994a, b, 1997, 1998, 1999). Test items (Table 1)
were generated in a manner so that they could
be categorized as belonging to one of eight content domains (subscales) . It was the investigators' a priori assumption that having individual
patient information for each of the subscales
would be important for the appropriate selection
and patient acceptance of amplification. Two of
the eight subscales contained items specific to
hearing aid use and related to
1. Motivation to wear hearing aids (Motivation)
(12 items) and
2. Expectations from hearing aid performance
(Expectations) (9 items) .
The remaining six subscales contained items
that were nonspecific to hearing aid use. These
categories were designed to assess a patient's perceptions of
3 . The importance of their physical appearance to others (Appearance) (10 items),
4. The cost of commercial goods and services
(Cost) (9 items),
5. Attitudes toward technology (Technology)
(7 items),
6 . Their own manual dexterity (Physical Function) (7 items),
129
Journal of the American Academy of Audiology/Volume 12, Number 3, March 2001
Motivation subscale
39M
43M
53M
61 M
62M
4M
14M
18M
23M
24M
27M
46M
Table 1 Items Comprising the Alpha Version of the HASP and
Associated Item-Total Correlation Coefficients (in Parenthesis) .
I want to wear a hearing aid even if I still have difficulty hearing in some situations .
I know that a hearing aid will help me.
I am prepared to do what it takes to improve my hearing .
I am certain that I want a hearing aid .
I am having a significant problem understanding speech .
I would rather do it myself than have someone else do it for me .
I am the type of person who needs to hear everything .
I have been embarassed in public because of my hearing .
I get very frustrated if I don't hear every word that is being said .
The decision to obtain a hearing aid is mine alone .
I have missed much in life because of a hearing problem .
I am always striving to improve myself .
(0 .48)
(0 .63)
(0 .61)
(0 .65)
(0.53)
(0 .20)
(0 .39)
(0 .44)
(0 .49)
(0,24)
(0 .34)
(0 .19)
Expectations subscale
35E
37E
41 E
68E
69E
12E
16E
52E
64E
A hearing aid will restore my hearing to normal just as eyeglasses restore vision to normal.
(0 .61)
I expect that my hearing aid will improve my ability to understand speech in background noise.
My hearing aid will make speech clear, distinct, and understandable in all situations .
A hearing aid will make it possible for me to understand speech in all situations .
My hearing aid will make speech sound natural.
I will not have to read lips when wearing my hearing aid .
I expect that I will learn how to operate my hearing aid immediately .
I will adjust to a hearing aid easily.
My hearing aid will never need repair.
(0 .55)
(0 .71)
(0 .77)
(0 .76)
(0 .36)
(0 .49)
(0 .30)
(0 .25)
Appearance subscale
5A
If I were losing my hair, I would get a transplant, wear a wig or toupee, or take medicine to make it stop.
10A I do not feel comfortable about leaving the house unless I look just right.
31A There is nothing wrong with using plastic surgery to improve one's appearance.
40A I am self-conscious about my appearance .
49A I am often concerned about how others view my appearance .
8A
I believe people should spend more time being concerned about how they look to others .
20A I am not content with my appearance .
25A I am concerned that wearing a hearing aid will make me look older.
26A If I had problems with my vision, I would wear contact lenses rather than eyeglasses .
54A I am very interested in my health and appearance .
(0.43)
(0.38)
(0.41)
(0.51)
(0 .69)
(0 .42)
(0 .45)
(0 .46)
(0 .32)
(0 .21)
Cost subscale
13C I am not an extravagant buyer
51 C 1 don't think that I need the best that money can buy.
55C When it comes to money, I don't like to take risks.
60C I am a price-conscious consumer
63C I only purchase items that I can afford.
1C
I am a bargain hunter.
9C
I believe that most products are overpriced .
22C I do consider myself a wise shopper.
48C I am not willing to pay more money for higher-quality products .
(0.39)
(0.35)
(0.47)
(0.48)
(0.38)
(0 .30)
(0 .37)
(0 .23)
(0 .25)
Technology subscale
2T
Computers have made our lives easier and better
11T I have or would like to have a cellular phone .
42T
I feel that new technology has improved our lives.
50T
1 like gadgets such as remote controls and find them very useful .
59T
1 have a microwave oven and have used one for many years .
57T When I purchase a new device, I always read the owner's manual .
67T
I feel comfortable programming my VCR to record a TV show .
(0 .43)
(0 .44)
(0 .40)
(0 .41)
(0 .37)
(0.16)
(0.38)
Physical Function subscale
33P
I do not have arthritis in my fingers .
38P
I have good sensation in my fingertips .
66P
I have no difficulty (or would have no difficulty) holding or shuffling cards .
(0.38)
(0.63)
(0.50)
19P
3P
36P
(0.44)
(0 .47)
(0 .25)
70P
130
I can hold my hands steady, in one position, for at least 10 seconds.
It is easy for me to use small objects such as paper clips, coins, small buttons, and/or zippers .
I do not have any difficulty touching my fingers to my ear .
My vision for reading is good (i .e ., my best vision with or without eyeglasses or contact lenses) .
(0.51)
Development of the HASP/Jacobson et al
Table 1 Items Comprising the Alpha Version of the HASP and
Associated Item-Total Correlation Coefficients (in Parenthesis) (Continued)
Communicative Needs subscale
21 CN It is very important for me to hear conversations with one other person .
29CN It is very important for me to be able to hear on the telephone .
44CN It is very important for me to hear the television and/or radio.
47CN It is very important for me to be able to hear in a place of worship, at a lecture, at a concert and/or movies .
65CN It is very important for me to hear conversations when 1 am in larger groups, for example, at a party.
15CN It is very important for me to hear conversations when I am in a restaurant .
Lifestyle subscale
32L 1 consider myself to be an active, busy, "on-the-go" kind of person .
34L Physical activity is an important part of my life .
45L
56L
1 enjoy going to movies, lectures, parties, restaurants, and/or the symphony.
1 am quite active and involved in lots of activities and social events .
7L
17L
28L
30L
I
I
I
I
58L
6L
I consider myself to be in good physical condition.
I like traveling and going on vacations .
have taken measures to live a healthier lifestyle .
am happiest when I am around many people .
spend very little time at home reading or watching television .
socialize often with friends and/or family members .
(0.50)
(0.60)
(0.52)
(0.54)
(0.68)
(0 .43)
(0.57)
(0.54)
(0.62)
(0.62)
(0.48)
(0 .32)
(0 .34)
(0 .37)
(0 .14)
(0 .38)
E = Expectations, M = Motivation, A = Appearance, C = Cost, T = (Fear of) Technology, P = Physical Function, CN = Communicative
Needs, L = Lifestyle
Items in italics were included in the beta (final) version of the Three-Cllnc HASP.
7 . Listening situations to which they are frequently exposed (Communicative Needs) (6
items), and
8. Their activity levels (Lifestyle) (10 items) .
Items were worded in such a way that they
could be answered on a 5-point Likert scale with
the anchors being strongly agree and strongly
disagree . A strongly agree response received 4
points and a strongly disagree response received
a score of 0 points . A neutral response received
a score of 2 points . The alpha version of the
HASP was administered using a paper-and-pencil format prior to hearing aid counseling but following the audiometric evaluation .
Results
Complete alpha version HASPS were
obtained from 120 of 130 subjects (92%), forming the data pool for the analysis . Ten subjects
provided incomplete data, which were excluded
from the analysis . Item E64 ("My hearing aid will
never need repair.") was the most frequently
unanswered item and was subsequently removed
from the beta version of the HASP.
The overall Cronbach's alpha was estimated
for each subscale as were the individual corrected item-total correlations . The objective of
this analysis was to group items in such a manner that a Cronbach's alpha value of 0 .70 or
higher would be obtained for each subscale .
Items were excluded if the corrected item-total
correlations were <_ 0 .30 . Following the initial
analysis, the alpha coefficients were reassessed
in an iterative fashion . This process ended when
all corrected item-total correlations were >_ 0 .30
and the alpha coefficient remained at approximately 0 .70 . As can be noted in Table 2, the
Expectations, Motivation, Appearance, Lifestyle,
Communicative Needs, and Physical Function
subscales had Cronbach's alpha values greater
than 0 .70, and each item-total correlation
exceeded 0.40 . The subscales of Technology and
Cost had alpha values just above 0 .66 with itemtotal correlations above 0 .30 .
Through this process, the beta (final) version
of the HASP was developed and is shown in
Table 1. The final version had a total of 40 items
that were comprised of the original eight subscales, each having five items . A patient's
responses to each item again were on a 5-point
Likert scale, with a strongly agree receiving a
maximum of 4 points and a strongly disagree
receiving a minimum score of 0 points . Accordingly, a maximum score for each subscale was
20 points (5 items X a maximum score of 4 points
for each item = 20 points) . It was decided that
the wording of the Cost and Appearance subscales was such that they should be reversescored for the subscale scores to be in a direction
consistent with the other six subscales (i .e ., a
131
Journal of the American Academy of Audiology/Volume 12, Number 3, March 2001
Table 2 Item-Total Correlations for
Items Comprising the Beta Version
of the HASP and Cronbach Alpha
Values for the Eight HASP Subscales
Alpha
Coefficient
Motivation
0 .84
Item #
M39
M43
0 .56
0 .69
M61
M62
0 .76
0 .53
M53
Expectations
0 .88
E35
E37
E41
E68
E69
Appearance
0 .69
A5
A10
A31
0 .66
Technology
0 .66
0 .73
Lifestyle
0 .79
0.77
0 .77
0 .45
0 .38
0 .32
C13
C51
C55
C60
C63
0 .48
0 .39
0 .41
0 .41
0 .38
T2
T42
T50
T59
0 .40
0 .46
0 .45
0 .33
0 .41
P19
P33
P38
0 .37
0 .42
0 .66
P70
0 .49
P66
Communicative Needs
0 .68
0 .55
0 .77
0 .83
0.49
T11
Physical Function
0.70
A40
A49
Cost
Item-Total
Correlation
Coefficient
0 .60
0 .45
CN21
CN29
CN44
CN47
CN65
0 .48
0 .61
0 .52
0 .55
0 .65
L32
L34
L45
L56
L58
0 .65
0 .61
0 .36
0.61
0 .49
greater subscale score is generally considered
more favorable from a clinical perspective and
a lesser subscale score is generally considered
less favorable) .
132
INVESTIGATION 2: EFFECTS OF
SUBJECT CHARACTERISTICS ON
HASP SUBSCALE SCORES
Method
Subjects
The beta version of the HASP was administered to another sample of 242 patients seen
for HAS appointments at the hearing aid centers of our three clinics. The mean age of this
sample was 66 .8 years (SD = 14 .0), ranging from
21 to 96 years of age. Table 3 summarizes the
demographic data for this sample of patients .
Table 4 displays mean audiometric data demonstrating that the majority of subjects had a sloping mild to moderately severe sensorineural
hearing loss with the mean word recognition
scores consistent with audiometric configuration
and severity.
Procedures
The HASP was administered after audiometry had been conducted but prior to any counseling associated with the HAS. As in
Investigation 1, the HASP was completed using
a paper-and-pencil format . In addition to completing the HASP, patients also completed either
the screening version of the Hearing Handicap
Table 3
Demographic Characteristics
of the Subject Sample
Reported in the Second Investigation
Variable
Gender
Male
Female
Age classification*
Young
Old
Education levels
< High school
High school
Associates degree
BA/BS degree
Postgraduate degree
Hearing aid experience*
Previous user
New user
Hearing handicapt
No hearing handicap
Mild-moderate hearing handicap
Severe hearing handicap
Sample Size (%)
135 (55 .8)
107 (44.2)
82(34 .0)
159 (66.0)
58
80
39
27
31
(24 .7)
(34 .0)
(16 .7)
(11 .5)
(13 .2)
114 (47.3)
127 (52 .7)
19 (7 .9)
84 (35 .0)
137 (57 .1)
Missing information for *one subject ; tseven subjects ;
ttwo subjects .
Development of the HASP/Jacobson et al
Table 4 Means and SDs for Right and Left Air-Conduction Thresholds (dB HL)
and Word Recognition Scores (Percent Correct) for Patients in Investigation 2
Frequency (Hz)
250
500
1000
2000
3000
4000
6000
WRS (%)
Right ear
Mean
37 .14
38 .91
44 .14
53 .03
61 .17
63 .45
6828
78 .82
Left ear
Mean
21 , 12
20 .74
20 .39
50 65
59 .91
61 .17
66 .16
81 .44
SD
SD
24 .88
21 .21
24 .31
20 .74
24 .31
20 .39
21 .87
19 .81
21 .13
18 .98
21 .75
20 .31
23 .67
20 .96
24 .10
19 .45
Inventory for the Elderly (HHIE-S ; Weinstein,
1986), for subjects who were 65 years and older,
or the Hearing Handicap Inventory for Adults
(HHIA-S ; Newman et al, 1991), for subjects
younger than 65 years of age . The HHIE-S and
HHIA-S are abbreviated (10-item) versions of the
full HHIE and HHIA. Each of the 10 items is
answered using a yes, sometimes, or no response
format . A yes response is scored as 4 points, a
sometimes response is scored as 2 points, and a
no response is scored as 0 points . Accordingly, a
maximum score on the HHIE/HHIA-S scales is
40 points, representing maximum self-perceived
hearing handicap . The hearing handicap classification system (Weinstein and Ventry, 1983)
used with the full HHIE-A was adapted for the
present investigation . A score of <_ 6 points on
either the HHIA-S or HHIE-S was considered to
constitute no hearing handicap . A score of
>_ 8 points and <_ 18 points was considered a
mild-moderate hearing handicap . A score of
>_ 20 points was considered evidence of severe
hearing handicap . As shown in Table 3, over
half (57%) of the subjects reported a perceived
sified as old . Table 5 shows a summary of results
for the HASP subscales . Only the Technology
(t = 4 .33, df = 239, p < .001), Physical Function
(t = 4.31, df = 239, p < .001), and Communicative Needs (t = 2 .16, df = 239, p = .03) subscales
reached statistical significance . Specifically,
younger patients tended to be more comfortable with high technology and had fewer physical (i .e ., manual dexterity) limitations . Older
Results
The effect of
Previous Hearing Aid Use .
previous hearing aid use on the HASP scores was
examined using Student's t-tests . As can be seen
in Table 7, there were no statistically significant
differences in the HASP subscale scores, with the
exception of the Motivation subscale . Previous
hearing aid wearers showed greater levels of
motivation than new hearing aid wearers
(t = 5 .19, df = 233 .1, p < .001) .
severe handicap .
Group Analyses
The sample was analyzed as a function of
age, gender, previous hearing aid use, educational level and by severity of self-perceived
hearing handicap (as reflected by the HHIE/A-S
scores). The following are the results of the
group analyses . The alpha level was adjusted to
compensate for repeated use of t-tests.
Age. Student's t-tests were used to examine
age effect on HASP subscale scores . Those
patients who were <_ 64 years were classified as
young and those who were >_ 65 years were clas-
patients had significantly fewer communicative
needs .
Gender. Student's t-tests were used to examine the effects that gender played in HASP subscale scores (Table 6) . Women showed greater
motivation to obtain hearing aids (t = -3 .16,
df = 240, p = .002), had greater expectations of
the hearing aids (t = -2 .47, df = 240, p = .01),
were slightly more comfortable with higher technology (t = -1 .95, df = 240, p = .05), and felt that
they had greater communicative needs than
men (t = -4.63, df = 240, p < .001). An unexpected
finding was that men were significantly more
appearance-conscious than women (t = 8.18, df
= 240, p < .001).
Education Level .
Educational background of
the subject sample was divided into five levels .
These levels served as the grouping factors,
with the HASP subscale scores serving as the
dependent variables for a series of one-way
analysis of variance (ANOVA) . Table 8 summa-
133
Journal of the American Academy of Audiology/Volume 12, Number 3, March 2001
Table 5 Means and SDs for HASP
Subscale Scores for Young and
Old Subjects in Investigation 2
HASP Subscale
Young
Motivation
15 .5
Expectations
13 .2
Appearance
8.0
Cost
5 .7
Technology
16 .0
Physical
16 .0
Communicative Needs 17 .1
Lifestyle
14 .8
Table 7
Old
p Value
(2 .9)
(3 .6)
15 .1 (3 .0)
12 .9 (2 .9)
35
58
(2 .6)
(2 .7)
(3 .0)
(2 .3)
(3 .0)
5 .8
14 .4
14 .0
16 .4
14 .1
(3 .4)
8.3 (3 .4)
(2 .6)
(2 .7)
(3 .6)
(2 .3)
(3 .1)
Means and SDs for HASP
Subscale Sc ores for Previous and
New Hearing Aid Users in Investigation 2
46
80
< .001
< .001
032
09
HASP Subscale
Previous User New User p Value
Motivation
Expectations
Appearance
Cost
Technology
16 .2 (2 .4)
12 .7 (4 .0)
14 .4 (3 .2)
13 .4 (3 .5)
< .001 *
16
5 .8 (2 .5)
15 .2 (3 .1)
5 .7 (2 .7)
14 .7 (2 .5)
91
16*
Communicative Needs
Lifestyle
16 .8 (2 .4)
14 .4 (3 .1)
16 .6 (2 .3)
14 .2 (3 .0)
63
66
Physical
8.4 (3 .5)
14 .8 (3 .7)
8.0 (3 .3)
14 .5 (3 .5)
29
56
Also shown are probability values associated with Student's
t-tests for each of the subscales.
Also shown are probability values associated with Student's
t-tests for each of the subscales.
*Welch's test used due to unequal variances .
rizes the results of the statistical analyses of the
data as a function of education level. Significant
group differences were observed for only two
subscales: Physical Function (F = 3.02, df = 4,
p = .02) and Lifestyle subscales (F = 3.18, df = 4,
p = .01) . Post hoc testing (Tukey) with Bonferroni correction for multiple comparisons (resulting in an adjusted alpha = 0.005) for the Physical
Function subscale revealed that individuals
with postgraduate degrees had less physical
limitations than individuals with a high school
education (t = -2 .99, df = 109, p = .003). Post hoc
testing for the Lifestyle subscale showed that
those with postgraduate education also had
more active lifestyles than those with a high
school (t = -3 .25, df = 87, p = .002) or less than
a high school education (t = -3 .49, df = 109,
p < .001).
with a one-way ANOVA. The HASP subscale
scores served as dependent variables, and severity of self-perceived hearing handicap (i .e ., no
handicap, mild-moderate handicap, severe handicap) served as the grouping factor. Significant
group differences were observed for the Motivation (F = 25 .9, df = 2, p < .001) and Communicative Needs subscales (F = 5.2, df = 2, p = .006). Post
hoc testing (Tukey with Bonferroni correction for
multiple comparisons resulting in an adjusted
alpha = 0.017) showed that, for the Motivation subscale, only the group comparisons between no
handicap and severe handicap and between mildmoderate handicap and severe handicap were
significant (no hearing handicap vs mild-moderate hearing handicap, t = -2 .0, df = 101, p = .04;
no hearing handicap vs severe hearing handicap,
t = -6 .10, df = 154, p < .001 ; mild-moderate hearing handicap vs severe hearing handicap, t =
-5 .83, df = 219, p < .001). Therefore, these findings suggest that a patient's motivation to obtain
hearing aids increases as his or her self-perceived
hearing handicap increases. Post hoc testing for
the Communicative Needs subscale showed that
the comparison of mild-moderate hearing handicap to those with severe hearing handicap was significant (t = -2 .69, df = 219, p = .008) . As
anticipated, patients with severe hearing handicap had greater communicative needs than did
patients with mild-moderate hearing handicap .
Magnitude of Hearing Handicap. Table 9
summarizes the results of the statistical analysis
on the basis of hearing handicap . The data were
analyzed separately for each of the HASP subscales
Table 6 Means and SDs for HASP
Subscale Scores for Male and
Female Subjects in Investigation 2
HASP Subscale
Males
Motivation
14 .7
Expectations
12 .5
Appearance
9 .6
Cost
6 .0
Technology
14 .7
Physical
14 .5
Communicative Needs 16 .1
Lifestyle
14 .1
Females
p Value
(3 .0)
15 .9 (2 .8)
002
(3 .1)
(2 .6)
6 .4 (2 .9)
5 .4 (2 .6)
< .001
.08
.05
52
< .001
(3 .5)
(2 .7)
(3 .0)
(2 .3)
(2 .8)
13 .7 (4 .1)
15 .4 (2 .8)
14 .8 (4 .1)
17 .4 (2 .1)
14 .6 (3 .4)
014
24
Also shown are probability values associated with Student's
t-tests for each of the subscales.
134
Percentile Plots. Figure 1 graphically displays the percentile data obtained for each subscale. As can be seen, for our patients, the 95th
percentile corresponded to a HASP score of 19
or 20 for six of the subscales (Motivation, Expectation, Technology, Physical Functions, Communicative Needs, and Lifestyle), suggesting
that our subjects were highly motivated, had
Development of the HASP/Jacobson et al
Table 8 Means and SDs for HASP Subscale Scores for the
Five Levels of Education for Subjects in the Second Investigation
< High School
High School
Associates Degree
BA/BS
Postgraduate
Motivation
Expectations
Appearance
15 .6 (2 .8)
14.0 (3 .6)
8 .5 (3 .4)
15 .1 (2 .7)
13 .0 (3 .8)
7 .5 (3 .3)
15 .5 (2 .9)
14 .4 (3 .7)
15 .2 (3 .6)
Technology
14.4 (26)
14 .6 (2 .3)
15 .6 (2,8)
Communicative Needs
Lifestyle
16 .7 (2 .3)
13 .8 (3 .0)
16 .8 (2 .2)
13 .9 (2 .7)
16 .5 (2 .3)
14 .8 (3 .9)
HASP Subscale
Cost
5.5 (2 .6)
Physical
14 .3 (3 .1)
5.8 (2 .7)
13 .9 (3 .7)
high expectations, felt comfortable with technology, had high communicative needs, and led
active lifestyles . On the other hand, the subjects,
as a group, tended to be concerned about appearance and especially the costs of goods and services as seen by lower scores for the Appearance
and Cost subscales . The interval between the
95th and 5th percentiles ranged from 7 to
13 points across the HASP subscales .
DISCUSSION
R
ecently, the emphasis in the audiology literature has focused on the application of
hearing aid outcome measures to address the
questions of treatment effectiveness (e .g .,
unaided vs aided benefit and satisfaction ; Weinstein, 1996), treatment efficiency (e .g ., differences
among aided benefit and satisfaction ; Valente et
al, 1997 ; Newman and Sandridge, 1998 ; Ricketts
and Dhar, 1999), and cost effectiveness (e .g.,
relative value among different hearing aids in
terms of purchase price ; Mulrow et al, 1990 ;
Newman and Sandridge, 1998) . Although sev-
eral instruments have been developed for the
expressed purpose of quantifying subjective fitting outcome (e .g ., Walden et al, 1984 ; Cox and
Alexander, 1995) or modified for purposes of
12 .9 (3 .7)
8 .3 (3 .4)
5.6 (2 .3)
15 .4 (3 .3)
11 .4 (3 .9)
8 .9 (2 .3)
5.9 (2 .3)
12 .8 (4 .0)
9 .1 (4 .2)
6 .2 (3 .1)
14 .8 (3 .8)
16 .1 (3 .0)
16 .0 (2 .9)
14 .2 (2 .7)
17 .1 (2 .2)
15 .8 (2 .6)
15 .0 (4 .5)
16 .1 (3 .2)
quantifying hearing aid benefit (e .g., Taylor,
1993), each fails to provide a systematic method
for assisting audiologists to select the "best"
hearing aid at the outset. In contrast, the HASP
is an attempt to provide information that may
assist the audiologist in the choice of hearing
instruments at the outset, thereby acting more
as an "in-come" rather than an "outcome"
measure . Our interest in the development of
the HASP grew out of frustration in not having
adequate tools to determine which specific style
and hearing aid options might best serve both
the audiologic and nonaudiologic needs of an
individual patient. As clinicians, we were fording that the majority of time spent during the
HAS appointment was directed toward providing patients with descriptive information about
the ever-increasing number of available hearing
aid technologies and designs . In turn, insufficient
time was left to assess the nonaudiologic factors
critical to the selection of an appropriate level
of technology and counsel the patient about
other management concerns (e .g., realistic expectations, adjustment) crucial to the overall success of the hearing aid fitting. Therefore, the
purpose of this study was to develop a measure
that might provide clinicians with a systematic
method for making a number of fundamental
Table 9 Means and SDs for HASP Subscale Scores for No Hearing Handicap,
Mild-Moderate Hearing Handicap, and Severe Hearing Handicap Groups in Investigation 2
No Hearing Handicap
Mild-Moderate Hearing Handicap
Severe Hearing Handicap
Motivation
Expectations
Appearance
Cost
Technology
12 .5 (3 .9)
12 .9 (4 .1)
8 .7 (3 .6)
14 .2 (3 .0)
13 .2 (3 .8)
16 .3 (2 .3)
12 .9 (3 .8)
14 .9 (2 .4)
15 .2 (2 .9)
14 .8 (2 .8)
Communicative Needs
Lifestyle
15 .8 (2 .3)
15 .1 (2 .8)
16 .2 (2 .6)
17 .1 (2 .1)
HASP Subscale
Physical
6.1 (3 .0)
14 .7 (4 .6)
8.4 (3 .8)
6.0 (2 .5)
15 .1 (3 .2)
14 .5 (2 .7)
8.1 (3 .2)
5.5 (2 .6)
14 .4 (3 .6)
14 .1 (3 .3)
135
Journal of the American Academy of Audiology/Volume 12, Number 3, March 2001
exploratory group demographic analyses
revealed several interesting observations .
Motiv
Expect
Appear
Cost
Tech
HASP Subscales
Phy
Func
Comm
Needs
Lifestyle
Figure 1 Display of "empty" matrix used to plot individual patient HASP subscale scores against the percentile responses of the subject sample . The lines illustrate
the 5th through 95th percentiles for each of the eight
HASP subscales. Please be aware that both the Appearance and Cost subscales are reverse scored (i.e ., a zero
subscale total is scored as a maximum, 20-point, positive
response). Motiv = Motivation, Expect = Expectation,
Appear = Appearance, Tech = Technology, Phy Func =
Physical Function, Comm Needs = Communicative Needs.
decisions during the HAS process based on several patient characteristics.
The HASP was designed to be administered
prior to the HAS appointment in order to provide the clinician with information regarding
patient motivation, expectations, communicative
needs, and lifestyles, as well as concerns/perceptions regarding cost, appearance, technology, and the existence of physical limitations. It
is noteworthy that items comprising only three
of the eight subscales (i .e ., Expectations, Motivation, and Communicative Needs) were
designed to relate specifically to hearing and
hearing aids . In contrast, the content of items
comprising the remaining five subscales was
designed to be more generic in nature, providing a more global picture of the individual . That
is, we believed that having a greater understanding of the patient's core belief and attitude system would be beneficial in constraining
the choices of hearing aids in the selection
process.
The results of the present investigation
demonstrated that the HASP has adequate internal consistency reliability for each of the eight
subscales. Further, the group performance on
each of the eight subscales was analyzed as a
function of age, gender, education level, selfperceived hearing disability/handicap, and previous hearing aid use. Although the relationships
among the demographic variables are probably
not completely independent, the outcome of the
136
As might be predicted, younger patients
were more comfortable with higher technology,
had fewer physical (manual dexterity) limitations, and reported greater communicative needs
in comparison with older adults . Studies have
consistently shown that older adults have fewer
communication demands in a variety of listening environments and fewer perceived emotional
and social/situational hearing handicaps (Gordon-Salant et al, 1994 ; Erdman and Demorest,
1998) in comparison with young adults . It is
not surprising, therefore, that older adults are
less likely to pursue audiologic recommendations, including being fit with amplification
(Dodds and Harford, 1982 ; Garstecki and Erler,
1996 ; van den Brink et al, 1996 ; Brooks and
Hallam, 1998) . Yet, in the present study, there
were no age-related differences observed for the
Motivation subscale . This finding is not surprising, given that the HASP was administered
to patients already scheduled for the HAS
appointment . That is, subjects enrolled in the
present investigation had already decided to
pursue obtaining amplification, thereby forming
somewhat of a self-selected subject sample .
Evaluation of gender differences demonstrated that women were found to be more highly
motivated and had greater expectations and
communicative needs. Previous studies have
suggested that women place greater importance
on communication in social situations (Erdman
and Demorest, 1998) and are willing to assume
responsibility for effective communication
(Garstecki and Erler, 1998).
Previous users demonstrated higher levels
of motivation toward hearing aid use than firsttime candidates . These results are not surprising, given the fact that this subject sample was
returning to pursue the purchase of new hearing aids when the HASP was administered.
For our subject sample, individuals with
higher levels of education were found to have
fewer physical limitations and a more active
lifestyle. Again, these observations were not
unexpected, given that higher levels of education
are more closely associated with white-collar
jobs, which are typically less physically demanding. In addition, there is a reported inverse relationship between socioeconomic level and
prevalence of disease and disability (Dunkle
and Kart, 1991). Accordingly, higher income
potentially results in greater access to medical
and preventive health care .
Development of the HASP/Jacobson et al
Lastly, as the severity of self-perceived handicap became greater, based on responses of the
HHIE/HHIA-S, motivation and communication
needs significantly increased . These findings
are consistent with other reports indicating that
individuals with hearing loss pursue audiologic
assistance only after they believe that their
hearing problem has progressed to a point where
they need intervention (van den Brink et al,
1996 ; Kochkin, 1998) . Accordingly, increases in
perceived handicap influence an individual's
likelihood to seek help and follow up on audiologic recommendations .
The percentile scores generated from the
present data set may be used to establish a reference to which the responses of individual
patients can be compared . That is, the percentile
data presented in Figure 1 may serve as a normreferenced benchmark against which to plot a
given patient's responses to the HASP. These
data are most helpful in demonstrating how the
HASP can be useful at the time of the HAS in
helping the clinician recommend the style and
level of technology for an individual patient . In
this regard, consider the following illustrative
cases :
0
Case 1 is a 57-year-old male attorney with
a bilateral precipitously sloping high-frequency sensorineural hearing loss above
1000 Hz . Following the audiologic evaluation, he was administered the HHIA-S and
scored 18 points, suggesting a moderate
perceived hearing handicap . At the beginning of the HAS appointment, he completed
the Client Oriented Scale of Improvement
(COSI; Dillon et al, 1997), indicating that he
specifically wanted to hear better in the
courtroom, during business meetings with
his partners and clients, when talking with
his young grandson, on the telephone, and
at restaurants . His scores on the HASP are
displayed in Figure 2 . Note that his scores
are at or above the 90th percentile except for
Appearance, which falls at the 5th percentile . Based on his high communicative
needs (COSI), the use of multimicrophone
technology was discussed ; however, this
option was eliminated following the patient's
expressed strong desire to obtain completelyin-the-canal (CIC) hearing aids only (see
appearance score on the HASP) . Therefore,
a seven-band, two-channel digital signal
processing (DSP) CIC hearing aid with a specially designed high-frequency ski-slope fitting rationale was recommended and fitted
2o
15
X10
Motiv
Expect
Appear
Cost
Tech
HASP Subscales
Phy Func
Comrn
Needs
Lifestyle
Figure 2 HASP for Case 1. Based on his profile, he is
strongly motivated, has high expectations (which may not
be realistic), is extremely appearance conscious (as noted
by the low score), is not concerned about the cost of goods
and services, is comfortable with technology, does not have
any significant physical limitations, has high communications needs, and has an active lifestyle . Note that the
X's represent the patient's data in this and future figures.
Motiv = Motivation, Expect = Expectation, Appear =
Appearance, Tech = Technology, Phy Func = Physical
Function, Comm Needs = Communicative Needs.
"
binaurally. His 3-week post HHIA-S indicated a significant reduction in self-perceived hearing handicap as indicated by a
post score of 6 points . This resulted in a
pre-/post-difference score of 12 points and
exceeded the critical difference value of 10
points, which is considered to be a true
change in perceived benefit following intervention (Newman et al, 1991) . The Knowles
Hearing Aid Satisfaction Survey (Kochkin,
1992) was completed 3 months postfitting
(Figure 3, A and B) . As can be seen, he was
satisfied with his hearing aids in a variety
of listening conditions . In this case, the
HHIA-S and the Satisfaction Survey outcome measures served as external criterion
validity indicators of the patient's benefit
from and satisfaction with amplification .
Further, this case illustrates the usefulness
of multiple assessment tools during specific
phases of the rehabilitative process-from
the initial audiologic evaluation (HHIA) to
the HAS (HASP, COSI) to the follow-up
appointments (HHIA, Satisfaction Survey) .
Case 2 is a 73-year-old retired female teacher
with a bilateral moderate-to-severe sensorineural hearing loss . Although retired,
she continues to volunteer as a tutor at a
neighborhood elementary school and is
active in her church. Her HASP is displayed
in Figure 4. Particularly noteworthy are
her apprehensions about technology (< 10th
137
Journal of the American Academy of Audiology/Volume 12, Number 3, March 2001
A
Satisfaction Rating
B
Satisfaction Rating
`o
N
Overall
Satisfaction
Improves
COL
Clearness
Improves
Hearing
Use in Noise
Natural
Sounding
One-to-One
Satisfaction Items
Small Groups
Large Groups Concert/Movie
Restaurant
Phone
Listening Situations
Figure 3 The Knowles Satisfaction Survey for Case 1. A illustrates how satisfied the patient is for selected items.
Note that "improves Quality of Life" (QOL) is rated on a 3-point scale rather than a 5-point scale. B illustrates satisfaction with specific listening conditions .
percentile), high communication needs
(> 50th percentile), and active lifestyle
(> 80th percentile) . Based on her profile,
an initial clinical decision may be to avoid
recommending "advanced technology" hearing aids . Following a brief discussion with
the patient, it was ascertained that she was
concerned with the use of remote controls or
"gadgets" and not opposed to the use of
newer signal processing strategies to
improve her communication abilities . The
patient was fit with binaural "mid-priced"
two-channel DSP in-the-ear hearing aids . On
postfitting testing, she had significantly
reduced her self-perceived handicap and
was very satisfied overall. Thus, a patient's
apprehension of technology does not pre-
clude his or her use of advanced signal processing hearing aids . It is important to note
that advanced technology hearing aids need
to be assessed from two perspectives : hardware (e.g., remote controls, memory switches)
and software (e .g., processing strategies and
fitting rationales) . For many individuals,
the newer signal processing technology actually offers a more simplified ("automatic")
approach to hearing aid use in comparison
with analog linear processing hearing aids
requiring the use of a volume control.
Further, patient profiles may assist audiologists
to better understand factors that may lead to the
rejection of amplification. Consider the following two cases:
"
Motiv
Expect
Appear
Cost
Tech
HASP Subscales
Phy Func
Comm
Needs
Lifestyle
Figure 4 HASP for Case 2. This case illustrates how
the HASP can be used for counseling with respect to
specific issues . The patient demonstrated a low score for
the Technology subscale, which might have resulted in
a recommendation for a traditional product, yet, when her
options were explained, the use of a specific type of higher
level technology was found to be most appropriate for her.
Motiv = Motivation, Expect = Expectation, Appear =
Appearance, Tech = Technology, Phy Func = Physical
Function, Comm Needs = Communicative Needs.
138
Case 3 is a 78-year-old new hearing aid user
with a bilateral, mild-moderate, highfrequency sensorineural hearing loss . She
demonstrated a HHIE-S score of 24 points,
suggesting a severe perceived hearing handicap . The HASP administered at the time of
the HAS is shown in Figure 5 . The profile
shows that the patient's score on the Motivation subscale fell below the 50th percentile for the subject sample . The scores on
the Technology subscale indicated that she
appreciates the benefits of technology, and
the results of the Physical Function subscale (5th percentile) indicate problems with
manual dexterity. Further, scores on the
Lifestyle subscale (below the 5th percentile)
suggest that she lives a relatively inactive
or sedentary life . The initial clinical decision
was made to accommodate the reduced manual dexterity by selecting an amplification
system that uses a remote control. This
decision was supported by her appreciation
of the benefits of technology. Therefore, she
Development of the HASP/Jacobson et al
Motiv
Expect
Appear
Cost
Tech
HASP Subscales
Phy Func
Comm
Needs
Lifestyle
Figure 5 HASP for Case 3 . Note that the Motivation
subscale score falls between the 20th and 50th percentiles
for the sample group. Whereas scores on the Technology
subscale indicate that the patient appreciates the benefits of technology, scores on the Physical Function subscale (5th percentile) suggest that she has problems with
finger/hand/arm mobility and scores on the Lifestyle
subscale (below the 5th percentile) suggest that the
patient lives a relatively inactive or sedentary life . Motiv
= Motivation, Expect = Expectation, Appear = Appearance,
Tech = Technology, Phy Func = Physical Function, Comm
Needs = Communicative Needs.
was fit binaurally with a full-shell, hybrid
analog/digital multichannel, multimemory
product with a directional microphone and
remote control ; however, her communication
needs, lifestyle, and motivation did not support the use of this system . It was not surprising that when she returned the hearing
aids for credit during the right-to-return
period, she commented that she stayed at
home "99 percent of the time" and did not
need the hearing aids . It might have been
predicted at the outset that a patient with
a sedentary lifestyle and with limited social
interactions may have difficulty experiencing the benefits of a hybrid analog/digital
multichannel, multimemory product with a
directional microphone and remote control .
Accordingly, follow-up intervention should
include investigating the use of assistive
listening devices for specific listening situ-
0
ations in the home in order to reduce the selfperceived handicap, as indicated by the
HHIE-S .
Case 4 is an 82-year-old female with a bilateral, mild to severe, sloping sensorineural
hearing impairment . Both the HASP and
HHIE-S were administered prior to the HAS
appointment . She scored 8 points on the
HHIE-S, suggesting mild perceived hearing
handicap . Her HASP is shown in Figure 6 .
Motiv
Expect
Appear
Cost
Tech
HASP Subscales
Phy Func
Comm
Needs
Lifestyle
Figure 6 HASP for Case 4. Note that all of the subscales
are at or below the 50th percentile with the Physical, Communicative Needs, and the Lifestyle subscales falling on
or below the 5th percentile of the subject sample. Motiv
= Motivation, Expect = Expectation, Appear = Appearance,
Tech = Technology, Phy Func = Physical Function, Comm
Needs = Communicative Needs.
Note that her score on the Motivation subscale falls far below the 50th percentile for
our sample, as do her scores on the Expectations, Cost, and Technology subscales .
Her score on the Physical Function subscale suggests that she has significant manual dexterity problems (< 5th percentile) .
Also, scores on the Communicative Needs
(5th percentile) and Lifestyle subscales (<5th
percentile) suggest that she has an inactive
lifestyle with limited social interactions .
The limited communication interactions
may account, in part, for the low score on the
HHIE-S, reflecting minimal perceived hearing handicap . She further reported that she
was at the clinic at the request of her daughter and physician . Although this patient
was a candidate for amplification based on
her audiologic evaluation, the results from
the HASP and the HHIE-S clearly suggested
otherwise . The patient and audiologist were
in accord that she was not ready to obtain
amplification at this time .
In summary, it is our contention that the HASP
has the potential to provide the dispensing audiologist with a number of practical benefits :
1 . Patient counseling : The HASP provides a
quick and efficient means to assess patient
motivation in obtaining amplification, their
expectations of what a hearing aid will and
will not do, and their degree of communication needs as a function of their lifestyle .
Additionally, the HASP provides insights
139
Journal of the American Academy of Audiology/Volume 12, Number 3, March 2001
2.
3.
4.
5.
140
into patients' beliefs and perceptions in
other areas that may influence the selection
of a particular hearing instrument . The
information obtained from the HASP can
then serve as a basis for counseling during
the HAS. Based on the profile, specific areas
can be queried for more in-depth understanding-for example, the issue of appearance as illustrated in Case 1 or the fear of
technology as in Case 2. Expectations can be
assessed as realistically high or not. Inasmuch as satisfaction represents the degree
to which we are able to meet expectations,
one might predict that patients having unrealistic expectations will be dissatisfied when
their hearing aids fail to meet those expectations . By appropriately assessing the
patient's psychosocial factors a priori, selection of the appropriate amplification system should be maximized-thus ultimately
increasing patient satisfaction and reducing
the rate of return for credit .
Clinician accountability : At present, there
is little empirical evidence to support the recommendation of a hearing aid for a particular patient. Yet, there is a plethora of new
technologies available to dispensing audiologists, and the task can seem overwhelming at times. Having a tool that
directs the audiologist to a particular style,
cost range, and/or level of technology, as
can be obtained from the HASP, would not
only be beneficial during the HAS but would
also serve as justification to support the
selection of a particular amplification
system .
Method for developing a pool of suggested
"first-choice" hearing aid types and styles :
The HASP, along with other subjective (e.g .,
COSI, HHIE-A) and objective measures
(e .g., audiometry), may prove instrumental
in developing an "expert clinician" algorithm that could generate a pool of "appropriate" hearing aid fittings drawn from any
manufacturer's product line. This is an exciting prospect, and the predictive accuracy
of the tool needs to be investigated .
Teaching graduate students and clinical fellows : The use of the HASP forces students
and clinicians to consider more than the
audiogram when selecting hearing aids . In
this regard, the HASP might serve as a good
teaching tool when supervising novice
clinicians .
Quality improvement projects documenting multisite comparisons: The content of the
HASP makes it possible to ask questions pertinent to whether there are differences in the
perceptions of patients seen at multiple
practice locations within the same system .
For example, one author (GPJ) has evaluated the differences in responses of patients
seen at seven Henry Ford Health System
dispensing locations within the Detroit Metropolitan area. The results of this analysis
suggested no differences in patient perceptions regarding any of the HASP subscales
despite the substantial differences in the
socioeconomic characteristics of patients
seen at some of the practice sites.
In conclusion, we have developed a selfreport prefitting tool with the following characteristics : (1) it is brief so that patients can
complete it within a reasonable time period
either at home or in the office setting ; (2) it is
easily administered and lends itself to either a
paper-and-pencil or computer administration
format ; (3) it can be used as a benchmark against
which a hearing aid candidate's profile of
responses can be compared against a larger
sample of individuals seeking hearing aids ; and
(4) it is broad in scope, assessing domains of
function that are important in the selection of
hearing aids .
Acknowledgment . The authors wish to thank the following individuals without whose help these investigations would not have been possible : Patricia Aldridge, MA,
Lisa Bauer, AuD, Jaynee H. Calder, PhD, Nancy Damron,
MA, William Dickinson, MA, Noreen D. Gibbens, MS, Lisa
Lee, MA, Christine Paul, MA, Wendy Rizzo, MA, Ginnette
Ruckel, AuD, Gail Sterling, MS, and Debra West, MA of
the Henry Ford Health System ; Deborah Bucher, MA,
Janet Fraser, MA, Ann Guzhauskas, MA, Julie Jones, MA,
Lorrie Lombardo, MA, Richard Nodar, PhD, and Cynthia
Wagner, MS, of the Cleveland Clinic Foundation ; and Jim
McPherson, MA, and Melissa DeJong, MA, of the Mayo
Clinic .
This manuscript was presented, in part, at the
American Speech-Language Hearing Association meeting in San Francisco, CA, November 18-21, 1999 .
REFERENCES
Brooks DN, Hallam RS . (1998) . Attitudes to hearing difficulty and hearing aids and the outcome of audiological
rehabilitation . Br JAudiol 32 :217-226 .
Cox RM, Alexander GC . (1995). The Abbreviated Profile
of Hearing Aid Benefit (APHAB) . Ear Hear 16 :176-186 .
Dillon H, James A, Ginis J. (1997) . Client Oriented Scale
of Improvement (COSI) and its relationship to several
other measures of benefit and satisfaction provided by
hearing aids . J Am Acad Audiol 8:27-43 .
Dodds E, Harford E. (1982) . A community hearing conservation program for senior citizens . Ear Hear 3:160-166 .
Development of the HASP/Jacobson et al
Dunkle RE, Kart CS . (1991) . Social aspects of aging and
communication. In : Ripich DN, ed . Handbook of Geriatric
Communication Disorders . Austin, Tx: Pro-Ed, 81-96.
Newman CW Sandridge SA. (1998) . Benefit from, satisfaction with, and cost-effectiveness of three different
hearing aid technologies . Am JAudiol 7:115-128 .
Erdman SA, Demorest ME . (1998) . Adjustment to hearing impairment II : audiological and demographic
correlates . J Speech Hear Res 41 :123-136 .
Newman CW, Weinstein BE, Jacobson GP, Hug GA .
(1991) . Test-retest reliability of the Hearing Handicap
Inventory for Adults . Ear Hear 12 :355-357 .
Garstecki DC, Erler SF. (1996) . Older adult performance
on the Communication Profile for the Hearing Impaired.
J Speech Hear Res 39 :28-42 .
Ricketts T, Dhar S. (1999) . Comparison of performance
across three directional hearing aids . JAm Acad Audiol
10 :180-189 .
Garstecki DC, Erler SF. (1998) . Hearing loss, control,
and demographic factors influencing hearing aid use
among older adults . J Speech Hear Res 41 :527-537 .
Taylor KS . (1993) . Self-perceived and audiometric evaluations of hearing aid benefit in the elderly. Ear Hear
14 :390-394 .
Gordon-Salant S, Lantz J, Fitzgibbons P. (1994) . Age
effects on measures of hearing disability . Ear Hear
15 :262-265 .
Valente M, Sammeth CA, Potts JL, Wynne MK, WagnerEscobar M, Coughlin M . (1997) . Differences in
performance between Oticon Multifocus Compact and
ReSound BT2-E hearing aids . J Am Acad Audiol
8:280-293 .
Kochkin S. (1994x). MarkeTrak IV: impact on purchase
intent of cosmetics, stigma, and style of hearing instrument . Hear J 47(9):1-7 .
Kochkin S. (1994b). MarkeTrak IV: will CICs attract a
new type of customer-and what about price? Hear J
47(11) :49-54 .
Kochkin S . (1997) . MarkeTrak IV : what is the viable
market for hearing aids? Hear J 50(1) :31-38 .
Kochkin S. (1998) . Marke'Irak IV : correlates of hearing
aid purchase intent . Hear J 51(1):30-38 .
Kocbkin S . (1999) . Marke`Irak V: "baby boomers" spur
growth in potential market, but penetration rate declines .
Hear J 52(1):33-48.
Mulrow CD, Aguilar C, Endicott JE, Tuley MR, Velez R,
Charlip WS, Rhodes MC, Hill JA, DeNino LA. (1990) .
Quality-of-life changes and hearing impairment : a randomized trial. Ann Intern Med 113:188-194 .
van den Brink RH, Wit HP, Kempen GI, van Heuvelen
MJ. (1996) . Attitude and help-seeking for hearing impairment . Br J Audiol 30 :313-324 .
Walden BE, Demorest ME, Hepler EE . (1984) . Self-report
approach to assessment benefit derived from amplification . J Speech Hear Res 27 :49-56 .
Weinstein B. (1986) . Validity of a screening protocol for
identifying elderly people with hearing problems . ASHA
28 :41-45 .
Weinstein BE . (1996) . Treatment efficacy : hearing aids
in the management of hearing loss in adults . J Speech
Hear Res 39 :S37-S45 .
Weinstein BE, Ventry IM . (1983) . Audiometric correlations of the Hearing Handicap Inventory for the Elderly.
J Speech Hear Disord 48 :379-384 .