Satisfaction with hearing aids among users of hearing health services

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1 Original Article Satisfaction with hearing aids among users of hearing health services Satisfação com Aparelhos de Amplificação Sonora Individual entre usuários de serviços de saúde auditiva Mirna Rossi Barbosa 1, Daniel de Sousa Medeiros 2, Gisele Marques Ribeiro 3, Luiza Augusta Rosa Rossi-Barbosa 4, Antônio Prates Caldeira 4 ABSTRACT RESUMO Purpose: To know the satisfaction with individual hearing aids among users assisted by the hearing care service of northern Minas, identifying the related factors and the perception regarding the care. Methods: This was a cross-sectional, exploratory study conducted in Northern Minas Gerais, with 302 individuals assisted by the Service of Hearing Health Care, who responded to a questionnaire assessing the hearing health service and satisfaction with the device. Logistic regression was used to assess the association between the sociodemographic variables and the satisfaction with the device. Results: The mean satisfaction with the device was 5.09 and of the service evaluation was 7.25, on a scale of zero through ten. At the time of the interview, 46% of interviewees reported that they were not using the device for over a month, and the majority claimed difficulties in adaptation. Patients who had questions about the use of the device exhibited lower satisfaction scores. Conclusion: Patients assisted by the Unified Health System, in general, reached an indicator of regular satisfaction with the device and a good indicator with the service offered. Keywords: Health Services Evaluation; Indicators of Health Services; Unified Health System; Patient Satisfaction; Hearing Loss; Hearing Aids Objetivo: Conhecer a satisfação com Aparelho de Amplificação Sonora Individual entre usuários assistidos pelo serviço de saúde auditiva do Norte de Minas, identificando os fatores associados e a percepção sobre a assistência. Métodos: Trata-se de um estudo transversal, exploratório, conduzido no Norte de Minas Gerais, com 302 indivíduos assistidos pelo Serviço de Atenção à Saúde Auditiva, que responderam a um questionário de avaliação do serviço de saúde auditiva e satisfação com o aparelho. Foi aplicada regressão logística para verificar a associação entre as variáveis sóciodemográficas e a satisfação com o aparelho. Resultados: A média de satisfação com o aparelho foi 5,09 e de avaliação do serviço foi 7,25, em uma escala de zero a dez. Na época da entrevista, 46% dos entrevistados relataram que não estavam fazendo uso do aparelho há mais de um mês, sendo que a maioria alegou dificuldades na adaptação. Os pacientes que tiveram dúvidas em relação ao uso do aparelho, apresentaram menores escores de satisfação. Conclusão: Os pacientes assistidos pelo Serviço Único de Saúde, de uma forma geral, alcançaram um indicador de satisfação regular com o aparelho e um indicador bom com o serviço ofertado. Descritores: Avaliação de serviços de saúde; Indicadores de Serviços; Sistema Único de Saúde; Satisfação do Paciente; Perda Auditiva; Auxiliares de Audição Work conducted at the Post-graduate Program in Health Sciences, Universidade Estadual de Montes Claros UNIMONTES Montes Claros (MG), Brazil, with scholarships awarded by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) and the Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG). (1) Post-graduate Program (Master s degree) in Health Sciences, Universidade Estadual de Montes Claros UNIMONTES Montes Claros (MG), Brazil. (2) Regional Superintendence of Education of Montes Claros, Secretariat of Education of Minas Gerais Montes Claros (MG), Brazil. (3) Post-graduate Program (Specialization) in Family Health, Department of Nursing, Universidade Estadual de Montes Claros UNIMONTES Montes Claros (MG), Brazil. (4) Post-graduate Program (Doctorate) in Health Sciences, Universidade Estadual de Montes Claros UNIMONTES Montes Claros (MG), Brazil. Conflict of interests: No Authors contribution: MRB principal investigator, development of the research, development of the schedule, survey of the literature, collection and analysis of data, writing of the article, article submission and article procedures; DSM coauthor, literature survey, data collection, writing of the article; GMR coauthor, survey of the literature, data collection, writing of the article; LARRB coauthor, survey of literature, collection and analysis of data, writing of the article; APC supervisor, development of the research, data analysis, correction of the writing of the article, approval of the final version. Correspondence address: Mirna Rossi Barbosa. Office 4, Av Cula Mangabeira, 562, Santo Expedito, Montes Claros (MG), Brazil, CEP: E- mail: mirnarossi@hotmail.com Received: 5/3/2013; Accepted: 9/11/ ACR 2013;18(4):260-7

2 Satisfaction of hearing aid users INTRODUCTION According to the Brazilian Institute of Geography and Statistics (IBGE Instituto Brasileiro de Geografia e Estatística) (1), 9.7 million Brazilians have some type of hearing loss. With the increase in life expectancy, it is estimated that this number may even be greater, since auditory function tends to deteriorate with age (2). The greatest challenge arising from hearing loss refers to the skills of speech recognition (3), which impairs an individual s communication and social relationships (4,5). In recent years, in Brazil, the Unified Health System (SUS Sistema Único de Saúde) expanded access to audiological care, with the establishment of networks of care for patients with hearing loss (6), which cover from the promotion of hearing health to speech therapy. Research is needed to assess the impact of such services and the effects provided for by the use of individual hearing aids (HA) (7), in order to ensure the effectiveness of treatment (8). The self-assessment questionnaires have been used in various services, helping to control the performance of users during the process of selection and adaptation to the HA (9). In 2000, a questionnaire containing seven items of self-rated satisfaction with sound amplification was proposed, aiming to achieve comparable data from different investigations and models of clinical services, called International Outcome Inventory for Hearing Aids (IOI-HA) (10). The questionnaire was translated for different countries. However, this questionnaire, in Brazil, was considered difficult to understand for people with low social-cultural level (11), who may not be able to answer it without the help of a professional service. This situation can lead to responses induced by the researcher (12). In addition, it should be noted that studies have used self- -assessment questionnaires to gauge user satisfaction, but these questionnaires are not sufficient to evaluate the quality of the service rendered (13). Following the establishment of hearing health indicators, a questionnaire of Assessment of the Hearing Health Service and Use of Individual Sound Amplification Device/hearing aid (HA) was recently published, with questions that assess, in addition to the assistance activities, the satisfaction of the user (7). In the present study, the goal was to get to know the satisfaction with hearing aids among users assisted by the hearing health service, identifying the associated factors and the perception regarding the assistance. METHODS This is a cross-sectional, exploratory, quantitative work conducted in Northern Minas Gerais, a region that encompasses 86 municipalities, with a population estimated at 1.5 million inhabitants. In this scenario, we carried out a survey of the population assisted by the Office of Hearing Health Care in Medium and High Outpatient Complexity, from January 2010 to August 2011, a period that represents the beginning of the actual work of the Regulatory Board of Hearing Health (JRSA Junta Reguladora de Saúde Auditiva), with a minimum of four months of receipt of the hearing aid. From the assisted population, we performed the selection of a simple random sample of users over 18 years old. The sample size calculation was performed considering the total number of individuals assisted, a margin of error of 5%, a confidence level of 95% and the frequency of the expected event of dissatisfaction of 30%, based on other studies (14). Patients with severe limitation of comprehension and expression to respond to questionnaires, and patients who were not located in their homes after three attempts, were excluded. The sample comprised 302 patients enrolled in the Office of Hearing Health Care in Medium and High Outpatient Complexity of the region, from 33 municipalities of eight micro regions of the North of Minas (Figure 1). Adapted from: Google Images Figure 1. Minas Gerais map with municipalities where the interviewed users resided The response rate was 98.7%. Regarding gender, 168 subjects (55.6%) were female and 134 (44.4%) were male. Most people who sought the hearing health service consisted of elderly, and 131 (43.4%) were aged between 60 and 79 years, 83 (27.5%), above 80 years and 88 (29.1%), between 19 and 59 years. Regarding education, 73 (24.2%) were illiterate, 143 (47.4%) had incomplete primary education, 32 (10.6%), completed elementary school, 38 (12.6%), completed high school and 16 (5.3%), completed higher education. With regard to occupation, 200 individuals (66.2%) were retired, 36 (11.9%) did not work or were unemployed and 66 (21.9%) worked. It was not possible to identify the type and degree of hearing loss of all individuals, because part of them did not have in his hands the printout of their audiometric tests and the Municipal Health Secretariat did not have data for all of the users. Among ACR 2013;18(4):

3 Barbosa MR, Medeiros DS, Ribeiro GM, Rossi-Barbosa LAR, Caldeira AP patients who had this information (n=160), the main type of loss was sensorineural and to a moderate degree. Data collection was conducted through visits to users living in urban and rural areas, by researchers who had no connection with the evaluated service, with use of the instrument Assessment of the Hearing Health Service and hearing aid use, a questionnaire that evaluates the service and hearing aid user satisfaction. The questionnaire consists of 17 questions that assess the overall service, the accessibility and the patient needs. Of these questions, four score the service from 0 to 10 and two score the user satisfaction from 0 to 10. The evaluation of the service refers to the service in general, the execution of tests with other types and/or brands of aids, the waiting time for the device, and the return to the service after receipt of the aid. User satisfaction is measured by the usage time of the device during the day, and at what time in the patient s life its use brought about improvements. The scores were obtained considering the suggestions of changes in a previous study conducted in northern Minas Gerais (7), whose cutoffs in concepts are: poor (0 to 2), regular (3 to 5), good (6 to 8), excellent (9 and 10). The questionnaire also has open questions that allow for the description of the reasons for not using the device, and satisfaction or dissatisfaction with the device. The open questions related to the reasons for non-use and to the satisfaction with the hearing aid, were grouped into categories and analyzed descriptively. In the bivariate analysis, the indicators of satisfaction with the hearing aid were dichotomized into satisfied (good or excellent) and dissatisfied (poor and regular). The sociodemographic variables, variables related to hearing aids and three other questions of the questionnaire were also transformed into dichotomous variables. The variables that had p values less than 0.30 were included in the multivariate model. Subsequently, we performed a logistic regression analysis, using SPSS (Statistical Package for Social Sciences), version 19.0, with a significance level of 5%. We also applied the Spearman correlation test to verify the correlation between the indicators of service evaluation and satisfaction with the hearing aids. This study was approved by the Ethics Committee of the Universidade Estadual de Montes Claros, under report 2888/11. The subjects were informed about the objectives and agreed to its realization by signing the Consent Form. At the end of data collection, when it was necessary, the interviewees received instructions from the researchers on various aspects of the use and adaptation of the hearing aid. RESULTS The characteristics of the devices recommended by the Office of Hearing Health Care are described in Table 1. The vast majority of respondents (81.1%) reported that they did not test with other brands during the selection process of Table 1. Characteristics of the Individual Hearing Aids offered by the Unified Health System Variables n % Type of Hearing Aid Behind-the-ear In-the-ear In-the-canal Completely-in-the-canal Category of the hearing aid* C B A Not reported Hearing aid fitting Binaural Monaural *Category C: digital programmable, non-linear, multichannel WDRC compression. Category B: digital programmable or not, mono or multichannel WDRC compression. Category A: non programmable, linear, monochannel compression the hearing aid and 53.6% did not return to the Service for a follow up a year later. Information about access and service to the users in the Service of Hearing Health Care are reproduced in Table 2. Of the 302 subjects, 139 (46.0%) were not using hearing aids for over a month, for the following reasons, according to the report of the interviewees: difficulty to adapt to the device due to discomfort, noise, pain in the ear, headache and rash (n=57); technical defects in the device (n=25), absence of benefit (n=23), financial difficulties, or in access, to acquire the battery (n=16); difficulties in operating the device (n=7); tube or mold defects (n=4); other reasons (n=7). Of the 139 individuals who were not using the hearing aid, 92 said they were satisfied with the device. When asked about the reasons for being satisfied, 54.5% claimed that the device helped them during the time they were using it, 22.9% said that the reason was that the device was free and 22.6% reported other reasons. The responses of the interviewees regarding the use and maintenance of the hearing aids are presented in Table 3. The average service evaluation was 7.25 and the satisfaction with the hearing aid was The mean and the standard deviation of each item comprising the evaluation indicators of the service and satisfaction with the hearing aid, are described in Table 4. In the bivariate analysis, age, occupation and level of orientation were associated with the satisfaction with hearing aids. When analyzed as a group, through logistic regression, only the variable guidelines regarding the use of hearing aids was associated with satisfaction, and dissatisfaction with the hearing aid was higher among those who reported questions regarding use of the device. The associations between 262 ACR 2013;18(4):260-7

4 Satisfaction of hearing aid users Table 2. Accessibility to the service of Hearing Health Care Variables n % Form of access to the service Formally forwarded Received orientation Spontaneous search Waiting time for care 0 to 3 months to 6 months to 12 months >12 months Test with more than one type/brand of hearing aid Yes No Waiting time for the hearing aid Less than 1 month to 3 months to 6 months >6 months Return for follow up * Yes No Global evaluation by user Excellent Good Regular Poor * In this variable only interviewees with time equal or greater than one year of receiving the device were considered, counted as of the date of the interview, during which the return to the service is necessary - or should be mandatory Table 3. Use and maintenance of the hearing aid and users of the Unified Health System Variables n % Use of the hearing aid during the visit Yes No Previous use of another hearing aid Yes No Orientations regarding the use of the hearing aid Feels sufficiently oriented Has questions regarding usage of the hearing aid Daily usage time of the hearing aid All day More than half of the day Less than half of the day Is not using it Satisfaction with the hearing aid Yes No Battery replacement No difficulties Financial difficulty Difficulty associated with distance Distance and financial difficulty Battery handling Perception of life improvement after hearing aid Yes Did not feel and improvement Table 4. Average and standard deviation of the indicators of satisfaction of users with hearing aid and with service (n=302) Criterion Maximum score Average Standard deviation Service assessment Test with more than one type/brand of hearing aid Wait time for the hearing aid Return to the service after receiving the hearing aid Global evaluation by user Satisfaction with the device Current use of the hearing aid Life improvement after the use of hearing aid the satisfaction indicator, the sociodemographic variables and the variables related to the use of the hearing aid, are presented in Table 5. Research on the correlation between the indicator of service evaluation and the satisfaction with the hearing aid indicator was significant (p<0.001), but weak (rho=0.245). DISCUSSION This study allowed us to evaluate the Service on Hearing Health Care and the result of the adaptation of hearing aids, from the perspective of the users. The average indicator of user satisfaction with the service was classified as good, ACR 2013;18(4):

5 Barbosa MR, Medeiros DS, Ribeiro GM, Rossi-Barbosa LAR, Caldeira AP Tabela 5. Associação entre satisfação com o AASI e variáveis sociodemográficas Variables Gender Indicator of satisfaction with the hearing aid Satisfied Dissatisfied (n) % (n) % Female p-value Crude OR CI (95%) Male Age group < Adjusted OR CI (95%) Education 8 years < 8 years Occupation Works Does not work/retired Type of hearing aid Behind-the-ear Intra-aural Category C A/B Previous use of another HA No Yes Orientation Feels oriented Has questions < * Hearing Aid fitting Binaural Monaural Test with brands Yes No *Significance level (p<0.05) Binary logistic regression Note: OR = Odds Ratio; CI = Confidence interval while with the hearing aid has been classified as regular. We emphasize this topic to demonstrate that the literature does not record studies that assess simultaneously both the satisfaction with the service and with the device, and service evaluations is scarce (13). Research that used other instruments to evaluate user satisfaction with their hearing aid (9,15-17), demonstrated higher levels relative to those in the present study. Within the view of quality control in treatment by health professionals, the user satisfaction index is pointed as one of the factors that must be analyzed. It is important to evaluate the effects provided by the use of hearing aids and by the services, with the goal of improving care practice in Audiology (18). In one Brazilian (9) and one American (17) study, that utilized the IOI-HA, the majority of users made effective use of hearing aids and declared themselves satisfied with the device. In another study (15), which used the questionnaire Satisfaction with Amplification in Daily Life (SADL), users registered high scores on all subscales of the instrument. However, this research contains a very limited sample when compared to the present study. Another aspect that could justify the low score of the indicator of satisfaction with the hearing aid, was the high proportion of individuals who were not making use of the device. In such situations, the score associated with satisfaction with the hearing aid was zero, which impacted on the final result. A high proportion of people who do not use hearing aids have been highlighted in another study (19). 264 ACR 2013;18(4):260-7

6 Satisfaction of hearing aid users It is noted, however, the peculiarity of the instrument, which, besides having gauged the satisfaction score, gauged the subjective perception of the user regarding satisfaction with hearing aids. This characteristic revealed a paradoxical situation, because the number of people who said they were satisfied with the device was very high, indicating that satisfaction is not always associated to the benefit provided by the devices, or their effective use (20). Among those who were not using the device, when asked the reason for the satisfaction, most responded that the device helped significantly; that they began to hear better with it. However, this benefit provided by the device referred to the time when they used it, i.e., the individuals were satisfied with a benefit that had in the past, even though the device did not offer any help when they were interviewed. Researchers (21) commented that the fear of losing access and affinity with the service professionals can lead users to omit negative opinions, reflecting a bias in satisfaction. A good portion of the interviewees also reported that they were pleased to having received the device for free. Some even associated this fact to a lucky event. This feeling of gratitude is observable in users of the Unified Health System, who do not see themselves as citizens with rights before the public service, which makes it difficult to assess the quality of the device, from the perspective of the user (12). This aspect can be better seen in the poorest regions, such as the study site, for example, which concentrates various cities with low Human Development Index (HDI). The effects provided by hearing aids may vary between individuals and the literature shows differences that vary according with geographic region. In Santa Maria - RS, the use of hearing aids was effective and the benefit quite satisfactory among users (9), as well as the cities of Recife (PE) (22) and Lauro de Freitas (BA) (23), where the level of satisfaction with the device was high. In Bauru (SP), two studies reported that respondents were satisfied with their hearing aids (24,25). However, one such study found that a significant portion of the sample had not returned for follow-up and some were not making effective use of the hearing aid (24). In João Pessoa (PB), individuals assisted by the Unified Health System, in general, did not get satisfactory results with amplification. Difficulties regarding the use and handling were identified, in addition to reduced daily use time of the devices, making it difficult to obtain the benefit (14). It is important to emphasize that the instruments used to assess satisfaction are different in some studies, and mostly include a small sample. Complaints about difficulties in adapting to hearing aids, similar to those reported by most people in this study that were not using the device, such as discomfort with the amplification caused by noise, headache, pruritus, among others, were also mentioned in another study (26) and require adequate monitoring by the health service to be investigated and remedied. The impact that the use of hearing aids causes in people s lives is diverse, depending on their physical, emotional, social and cultural conditions (20). While for some the device has been representing a significant improvement in their quality of life, for others the impact has not been observed in a significant way. References to defects in the device, or difficulties in obtaining the battery, by access inability or financial matters, indicated by some patients in the present study as reasons for not making use of hearing aids, can be based on the fact that, despite having auditory rehabilitation guaranteed by the Unified Health System, there are monetary costs involved in the maintenance of the appliance, which are the responsibility of the patient, which could explain the delay in seeking resolution to the problems encountered (26). Even among those who were making use of hearing aids, some users reported that they do not use it full time to save the batteries. The difficulty to replace the battery due to access occurred, especially in smaller municipalities. Although the majority of the interviewees reported that they feel sufficiently oriented to use the hearing aid, the association between satisfaction and guidance on how to use the hearing aid, identified by means of the logistic regression, revealed that the difficulties in handling the device directly interfere with the effective use of the hearing aid (2,14). This result reflects the importance of the active participation of the family in the rehabilitation program (27) and highlights the importance of access to information, which can be best obtained via the systematic monitoring of the patient. The indicator of satisfaction with the service, in which the scores obtained in interviews with users conceptualized it as good, with more than half of users rating the overall care as excellent, praising the treatment received from the professionals, agrees with the results of the multicenter study conducted in Bauru, with the intent of developing an instrument to evaluate the service quality of hearing care. In this instrument, users of Unified Health System also said they were satisfied with the service, and the best scores of the questionnaire were related to professional competence, hearing evaluation and personalized attention (13). Patients who are satisfied with their hearing aids also feel grateful to the professionals that offered it to them (17). The observed correlation between the indicator of service evaluation and the indicator satisfaction with the hearing aid was positive and significant, however, it explained only a portion of the results, since the correlation was weak. The average of the indicator assessment of the service was classified as good because the vast majority of users did not test other types/brands of devices and many did not return to the service after receiving the hearing aids. The ordinance SAS/ MS nº. 587 of 2004, of the Ministry of Health, which regulates Hearing health services recommends testing three types and/ or brands of devices at the time of selection. Although the lack of tests with different types and brands can contribute to the difficulties of adapting users (9), in this study, this variable was not associated. ACR 2013;18(4):

7 Barbosa MR, Medeiros DS, Ribeiro GM, Rossi-Barbosa LAR, Caldeira AP The large number of people who did not return for follow-up in the Service is a fact that deserves attention. Some subjects reported that they did not know that they should return after a year, and also stated that they were not called. This annual monitoring in the case of adults and the elderly, is also established by ministerial order. At the end of the speech therapy, the patient receives a guide with information on the monitoring, which can be scheduled by the audiologist, decentralized/ technical reference of the municipality, or the service itself. Researchers conducted a quantitative survey of the procedures related to the adaptation of hearing aids in Brazil and found that parallel speech therapy is still poorly implemented. Thus, the services need to be organized to investigate the reasons for the non-performance of this procedure in patients fitted with hearing aids (6). The hearing aid is the beginning of the process of rehabilitation of persons with hearing loss, but therapy after adaptation is crucial to reduce communication barriers. Users of hearing aids undergoing rehabilitation with training of hearing skills had greater benefit when compared to those who did not undergo the same procedure (28), increasing the effective use of hearing aids, using more communication strategies in everyday life and improving their quality of life (29). Thus, many of the inconveniences reported by interviewees could be resolved in these meetings. The orientation of the patient, before and after the adaptation, is also essential to reduce their hearing handicap and their anxiety (30), because excessive expectations regarding the use of hearing aids can lead to frustration and abandonment of the device. Strategies that minimize the lack of adherence to treatment need to be developed so that the resources spent with hearing impaired individuals do not culminate in waste, as already highlighted by another study (24). The link between Primary Health Care and the Office of Medium and High Complexity can be one of these strategies, as it would ensure comprehensive care to the patient. The training of Community Health Workers can be a viable solution for the continued education of hearing aid users. Further studies should be conducted to evaluate this possibility. New studies to improve the accuracy in the evaluation of user satisfaction are needed, too, since the existing studies recorded important differences between them. The questionnaire used in this study was considered easy to use and understand, being useful for the control of quality of service. Instruments that assess the quality of service in other segments, such as the structure, and with different actors involved in the process, such as professionals and managers, should be used in order to ensure effective care. The assessment of hearing health services is needed in order to add improvements to the Policy of Hearing Health Care (12). The results of this study should be considered in light of some limitations. It was not possible in this research to have all the data needed for a thorough analysis, with respect to the type and severity of the hearing loss. A significant number of patients did not have copies of their exams, which is at odds with current legislation. The fact that the study used an instrument that is not widespread also limits the comparative analyzes with other studies. An alternative to overcome these limitations would be to conduct a longitudinal study in future research. It should be noted, however, that the present study included a large sample, representative of a large geographical area, with analysis of data collected directly from patients. CONCLUSION The results obtained via the indicator of satisfaction with hearing aids had levels below that reported in other studies, due to the high number of individuals who were not making use of the device. Dissatisfaction was highest among those who had questions about the use and handling of the device. The perceived discomforts were the causes of the problems in adaptation and need to be further investigated and remedied. Actions required by the law, such as tests with different types and/or brands of devices and annual monitoring, were not recorded in the interviews with most users assisted in the service. However, they are satisfied with the professionals and service offered, which may be a result of the feeling of gratitude, common among users of the Unified Health System. REFERENCES 1. 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