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Figure 1: The implicit audiological trajectory of impairment and intervention
Intervention as a
means of rehabilitation
The five red arrows illustrate the different points of entry and consist of:
1. Approximately 8 weeks before the dispensing: Permission letter/informed consent 2. The same day of the dispensing: Prefitting interview (10-20 minutes)
3. Immediately after the prefitting interview: Video recordings (nonparticipant observation) of the dispensation of the hearing aids (45 minutes)
1.Population with varying hearing function
2.Assess this population (screening)
3.Individual assessment
4.Fitting and patient education or referral
5.Available follow-up education
1st point of entry:
Permission letter/informed consent
2nd point of entry : prefitting interview
3rd point of entry:
Video recordings (nonparticipant observation) of the dispensation of the hearing aids
4th point of entry:
postfitting interview
5th point of entry: follow up survey on patients’
use of post requisition offers
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4. 6 weeks after the dispensing: Postfitting interview (20-60 minutes)
5. One year after the dispensing: Follow-up survey regarding patients’ use of postrequisition offers
The following is a description of methodology concerning this part of the project. My reflections in relation to choice of methodology follow on page 53.
First point of entry: Permission letter/informed consent: Patients show up in the audiological clinic when referred from their general practitioner. In this pre-encounter, they are individually assessed, have hearing tests, and are provided with a diagnosis. If the physician decides that hearing aids are the appropriate treatment for their hearing impairment, they are placed on a waiting list.
From that waiting list, I made a consecutive selection of patients. The criteria were that they were first-time users, of working age, and could speak and read Danish14. Patients were contacted by letter 4 weeks before the dispensation of hearing aids, and they were asked to join the project and to fill out a permission letter (informed consent). In the letter, I presented myself as a master in
education and a Ph.D. fellow. Over the 6 months, a total of 58 people were contacted. Seventeen of them declined, and I have no data on reasons for not wanting to be part of the project.
I might have been able to paint another picture of e.g. the group of young first-time users, the group of women compared with men, or the group of immigrants, had I aimed at conducting a strategic sample instead of a consecutive. However, at the time I did not know what to anticipate. Hence, the random sample of 41 participants who chose to join my project ranged in age from 20 to 70 years, with a mean age of 56:
Age in years 20-30 31-40 41-50 51-60 61-70
number 1 4 8 7 21
14In my project, I had not budgeted either for an interpreter(s) or for information material to be interpreted into several languages. Hence, participants’ knowledge of Danish was decisive for their participation, since I consider a lack of language fluency to be a complicating factor with difficulties in separating the problems of hearing impairment from a lack of language comprehension.
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The group consisted of 21 women and 20 men15. Two of the patients were immigrants from Eastern Europe, two patients were German, one patient was Dutch, and the rest were ethnic Danes. There were no criteria as to degree of hearing impairment. Some were classified as having mild to severe hearing impairment, while others had hearing impairment that differed for each ear. The functional and biological issues associated with hearing impairment are inconsequential to this project, as I was interested in patients’ subjective experiences. In addition, it is well established that self-perceived hearing disability has little relationship to measurable hearing thresholds (Eriksson-Mangold & Ringdahl, 1992; Garstecki & Erler, 2001). Another aspect is length of time that this group had lived with their impairment. Within rehabilitation research, one finds discussions about the different phases in the receptivity and adaptation period (Engelund, 2006; Gullacksen, 2002).
However, research has shown that there is no correlation between the onset of hearing impairment and self-reported problems in relation to this (Danermark & Coniavitis Gellerstedt, 2003: 136). My group varied from having no sense of having hearing problems to having been aware of hearing problems since late childhood, with a mean time for awareness of 5 years.
According to patients’ journals, they had not entered the hearing clinic with a range of other diagnoses. Yet ten of the patients told me that they suffered from tinnitus to varying degrees. A consideration of this aspect is beyond the scope of the dissertation. They were all fully functioning working people and represented a range of socioeconomic backgrounds. As for the audiologists, ten were asked to join the project and two of them declined16. The eight remaining were six men and two women ranging in age from 29 to 58 years. On the day of the dispensing of the hearing aid, patients were allocated to those among the audiologists who had consented to being video-recorded.
Patients agreed to their data being used as long as anonymity was preserved, and to that effect, names and identifying information have been changed in the articles. Both staff and patients were advised that the recordings would be kept confidential and would be viewed by only my research colleagues, including my two supervisors, and myself. As mentioned in the report from the Danish
15 Men are often described as having auditory functions that are less sensitive than those of women (Gates,
Couropmitree, & Myers, 1999), and they become progressively less sensitive as they age. These changes in the man’s hearing have been attributed to greater exposure to environmental noise (Henry, 2004). This subdivision, though, is not reflected in my group of patients.
16 Actually, a whole group of audiology technicians in hospital no 2 where I video-recorded hearing aid fittings decided collectively not to participate in my project. Two differently educated groups of staff were doing the same job (fitting hearing aids) and only those with a 5-year university degree accepted the invitation to join my project. This indicates that there might have been potential conflicts amongst the two groups regarding who was best suited to do the job and that having their work being video-recorded would put them in danger.
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National Centre for Social Research (Christensen, 2006), many never seek audiological help, which means that the estimated prevalence and incidence of hearing impairment is higher than the number of people who show up at hearing clinics. Thus, my choice of selection procedure means that the group of people who do not seek audiological help, despite having a medically defined hearing impairment, are not considered in my dissertation.
Second point of entry: Prefitting interview: To follow up on the permission letter, I repeated that I was a researcher in social sciences and that I did not have much knowledge about audiology or hearing aids. Based on a semistructured schema (see attachment 1), I conducted a short audio-recorded interview (lasting approximately 15 minutes) with the patient in a vacant room in the hearing clinic just before the hearing-aid fitting. Not all questions were asked of all patients, and not all questions were phrased in the same way or delivered at the same stage in each interview.
As all patients had impaired hearing, this may be considered a practical challenge. Poor hearing e.g.
might make a person less willing to be interviewed. However, I aimed at speaking slowly and clearly, and this worked out well. In these interviews, I sought to learn about the patient’s decision about their commitment to, and experience of, the rehabilitation program on offer.
Primarily because of limited time (patients had told me that they would join my project as long as it would not extend their stay at the hospital longer than anticipated), I asked the patients to fill in a questionnaire about socioeconomic aspects of their lives17. In this questionnaire, they were also asked about social support resources, frequency of social interaction, and availability of a
confidant/-e. This is a part of my research with which I have dealt only tangentially in some of my articles. The more biographical aspects of the patients are dealt with in the articles only where it is activated by the specific situation.
Third point of entry: Video recording of the fitting and dispensation of hearing aids: the hearing-aid fitting is where the patients are provided with hearing aids with the aim of
reconstructing their soundscapes. I was concerned about the ability to simultaneously record both patient and audiologist interaction. Observation takes on different aspects according to how one is
17 Three of the patients chose not to fill out the questionnaire, as they considered questions on socioeconomic matters to be intrusive.
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positioned within the room. Only by seeing the fitting encounter (which included a patient, sometimes a significant other, an audiologist, and sometimes a trainee) from the perspective of all patients could I come to understand the interaction order (in some situations also the motivations and meanings that underlie their participation). Thus, instead of using observation in the more traditional way with me in the room as an observer noting down what I saw, I chose to video-record the interactions. As the fitting rooms were quite small, it would have been difficult for me to be able to see both the face of the audiologist and of the patient without the use of cameras. Therefore, I placed two cameras in the room: one focusing on the audiologist (and the trainee if one was present) and the other focusing on the patient (and the significant other if one was present). I turned the cameras on once the patient was seated in the assigned chair, and then I left the room. After the recordings were completed, with the use of a software program (Corel Video Studio), I mixed the audiologist and patient camera images into a split-screen video record in which the actions of the audiologist had an inset (top right-hand corner) of the actions of the patient at that particular time.
This combined video record allowed the actions of the patient to be seen in relation to the actions of the audiologist.
Fourth point of entry: Postfitting interview: Subsequent to the prefitting interview and the interaction observed during the hearing-aid fitting on the video recordings, the postfitting interview was conducted 6 weeks later, following the fitting and dispensation of the device18. In Denmark, as I will demonstrate, the public sector considers this type of service audiological rehabilitation. As described by Kramer et al. (2005), it corresponds with similar services offered by most European countries in which audiological rehabilitation likewise is restricted to hearing-aid fitting only.
Supporting this argument is Hogan (2001: xi), who recounts his experiences from the Australian continent. He describes in the introduction of his book concerning psychosocial rehabilitation for deafened adults how the hearing impaired he met: ‘...had sought out every form of help they could find, and spent all they had on expensive hearing aids, but to no avail. They had been left to fare as best as they could in the world without adequate assistance and support. Hearing loss had
18 The preliminaries unveiled that all patients are explained that becoming a new hearing aid wearer is a process requiring 6 weeks to take place and that prolonged and repeated exposure to amplified sound enables the brain to learn better and understand amplified speech during this time. It is emphasised that the patient should wear the aid long enough to allow the medically defined acclimatisation to occur, i.e. that the abnormal sound will eventually be perceived as the new normal sound. The arguments for increasing use are that without audio stimuli, the brain forgets how to interpret the meaning of sound. This information is based on the work of Stuart Gatehouse (1992) and by staff members who call this ‘the Gatehouse effect’; it is treated in further detail in articles II and III.
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devastated their lives and left them on the margins of society as impoverished, isolated, and broken people’.
The timeframe for what is considered audiological rehabilitation in a few other countries – e.g. in Sweden – might differ from this very short period (for further information on this topic, see attachment 2 concerning Stratton’s dissertation on audiological rehabilitation in Sweden).
Nonetheless, when I discuss rehabilitation in this dissertation, I follow a – if not global – then at least a Danish political-administrative construction of the concept. I will return to this issue in the conclusion.
I used a very flexible and responsive structure when questioning patients regarding the use of the hearing aid, benefits, problems, etc. These interviews lasted from 20 to 60 minutes. Those that lasted longer were with a female interviewee. The aim was to explore the everyday trajectory of impairment and intervention, and the video recordings were used as an opening for the interview to stimulate patients’ reconstructive accounts of the encounter events: What did the patient receive from the training given and what did it mean to him/her? Specifically, in relation to the
dispensation, which components were experienced as useful to the patient? Which phenomena were focused on? Were the aids used? How and when?
The postfitting interviews were conducted by telephoning the patients after working hours in their homes. Telephone interviews were chosen, as the piloting of three preliminary interviews showed that the patients gave consent provided that they did not have to come to the hospital. Thus, after having conducted the prefitting interview, I asked patients to provide me with a phone number and a time of the day when I could reach them. I told them that the postfitting interview would last up to one hour and all stated that they then preferred to be phoned at home in the evening and all gave me their home number. Some of the participants were called several evenings in a row before I finally reached them.
All postfitting interviews were tape-recorded by the use of special equipment provided by the hospital and transcribed by me over the following days.
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Fifth point of entry: Follow-up survey on patients’ use of postrequisition offers: By use of a database at the hospital, I tracked how many of the patients had contacted the hearing clinics a year after the provision of hearing aids. I was allowed to see the patient’s journal of those who had made contact in which the purpose and the outcome was described by the health professional involved, whether that was a physician, an audiologist, a psychologist, or an ear mould technician. It turned out that one out of the 41 patients in my study had contacted the communication centre for
additional instruction, and 8 patients had contacted the hearing clinic for a readjustment of their hearing aids. Thus, the number of follow-up visits was limited to 25 %.