perceptions about hearing aids from elderly non-users: a bicultural point of view (italy & usa)

8/8/2019 Perceptions about hearing aids from elderly non-users: A bicultural point of view (Italy & USA)

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PERCEPTIONS ABOUT HEARING AIDS FROM

ELDERLY NON-USERS:A BICULTURAL POINT OF VIEW (ITALY & USA)

by Beatriz C. Alvarado M., Au.D., CCC-A


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ABSTRACT

PERCEPTIONS ABOUT HEARING AIDS FROM ELDERLY NON-USERS:

A BICULTURAL POINT OF VIEW (ITALY & USA)

Perceptions about hearing aids can vary across people o dierent cultural backgrounds

depending upon belies, healthcare policies, education, etc. This study investigated the

perceptions about hearing aids o non-user elderly subjects rom Italy (IT) and the United States

(US) who complained o hearing loss with regard to: benet o hearing aids, cosmetic appearance

o hearing aids, cost o hearing aids, social pressure about the use o hearing aids, and about

the primary provider or hearing aid services. A 15-item survey called Perceptions about hearing

aids rom non-users (PHANU) was developed and administered to 184 subjects in IT and

160 subjects in the US. The subjects consisted o a random sample o 60 year-old non-users o

hearing aids who reported diculty hearing. There were two subject groups in each country: aclinical ITC/USC and non-clinical ITNC/USNC.

The PHANU survey items were analyzed using the Rasch rating scale. Signicant dierences

were observed or survey questions pertaining to social pressure, cost, and benet between

the USC and USNC groups. The ITC and ITNC groups demonstrated signicant dierences with

regard to cosmetic and benet questions. Signicant dierences with regard to social pressure

aspects were observed between the USC and ITC groups. The USNC and ITNC groups showed

signicant dierences with regard to benet and cost. Audiologists were the predominant hearing

aid provider in both US groups. Otolaryngologists were preerred in both IT groups. The USNC

group had the most positive perceptions

about hearing aids.

The PHANU survey revealed that subjects rom IT and the US can have contrasting opinions

about hearing aids. Questions pertaining to cosmetics, benet, and social aspects could

potentially relect a cultural component about hearing aid perception among the subjects

surveyed. However, questions regarding cost and provider depend greatly on the healthcare

structure o each country. The PHANU survey demonstrated good validity and reliability. Due

to the surveys experimental design, test-retest reliability indexes could not be obtained. Future

modications should include cultural trait questions, increased sample size, gender/age/context

variations, and re-wording o questions. PHANU shows promise as a tool that can benet the

hearing-impaired, proessionals, industry, and healthcare policy makers.


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INTRODUCTION

Many people all over the world will experience hearing diculties as their bodies age. However

some people with hearing loss will seek the help o hearing aids while other people will not.

Although some elderly individuals may acknowledge a change in hearing with age, some elderly

people report that they experience no communication problems, and are able to postpone or

avoid the use o hearing aids or a very long time (Brooks, 1978; Kyle et al, 1985). Preerence ornon-use o hearing aids among older adults who are candidates or amplication remains to be

explained even though several studies have examined the contribution o consumer attitudes,

behaviors, and lie circumstances to this phenomenon (Garstecki & Erler, 1998, p.527).

A study by Duijvestijn et al (2003) in the Netherlands evaluated the actors infuencing help-seek-

ing behavior in 1419 hearing impaired subjects aged 55 years. The study revealed that ewer

than hal o the subjects diagnosed with hearing loss exceeding 30 dB had visited their genera

practitioner with complaints o hearing impairment. The subjects had a hearing test and were

asked how they perceived their hearing by using a structured questionnaire. Fity-sevenpercent o the group o subjects who had not sought help rom a general practitioner judged

their hearing as poor. The authors concluded that help-seeking behavior o hearing-impaired

elderly people is related to the social pressure exerted by signicant others, to the degree o

hearing disability, and to the willingness to try hearing aids.

Hietanen et al (2004) perormed a 10 year longitudinal study in Finland about changes in the

hearing ability o 80 year olds. There were 291 subjects in the sample. The study revealed a

signicant deterioration in the hearing status o the subjects over time. However, the change in

sel-evaluated hearing diculties was not signicant. The authors ound that hearing aids werenot used by over 75% o the people who had a moderate hearing impairment. The researchers

concluded that hearing deterioration in elderly people and their low level o use o hearing aids

require closer attention in the healthcare system.

In Germany, a study perormed by Hesse (2004) on 331 subjects (60 years o age) demonstrated

that the acceptance o hearing aids by the elderly is generally poor. Hesse perormed complete

audiological assessments on all subjects and ound that only 15.3% o the subjects that needed

hearing aids were provided with them. Hesse recommended improvements in the regulation o

hearing aid provision among the elderly in conjunction with an adequate audiological rehabilitationplan.

Non-users o Hearing Aids

Kochkin (2005) reported that more than 22 million people in the United States have never tried

hearing instruments as a solution to their hearing loss. According to a study conducted in the

United States in 2004, there were 24.1 million individuals with a hearing loss who did not own

a hearing aid device in contrast to 12.5 million individuals who owned hearing instruments and


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11.1 million individuals who used their instruments (Kochkin, 2005). Inormation on the status

o non-hearing aid use among the elderly in Italy was not ormally published at the time o data

collection o this study in 2005.

According to Kochkins study (2005) in the United States about 6 out o 10 hearing instrument

owners and non-owners are male. The role o psychological actors in contributing to the

decision o an individual to elect to opt out o device use remains to be proved. Kochkin (2005)

stated that some o the reasons that hearing-impaired people delay the use hearing aids

include: inadequate inormation, stigma, cosmetics, misdirected medical guidance, not realizing

the importance o hearing, not believing that hearing aids work, ailing to trust in the hearing

proessional, unrecognizing the value o hearing aids, and eeling that hearing aids are not

aordable.

According to Erber et al (1996), elderly non-users o hearing aids have given many reasons

or rejecting them including discomort, visibility o the device, lack o belie in benet, and

environmental intererence. Hearing loss and use o hearing aids are widely reported as

unacceptably dierent rom normal or stigmatizing. Perceptions o stigmatization most oten

result in denial o hearing problems and lack o adherence to proessional recommendations to

use hearing aids (Erler & Garstecki, 1998).

Prevalence o Hearing Loss

According to the American Speech-Language-Hearing Association (ASHA) (Castrogiovanni

2006), clinical data to determine i hearing impairment rates are changing are not available since

there are no ongoing, clinical, annual studies o hearing impairment in the United States (Lee

et al, 2004). Data collected rom Federal surveys illustrate the ollowing trend o prevalence or

individuals aged three or older: 13.2 million (1971), 14.2 million (1977), 20.3 million (1991), and

24.2 million (1993) (Ries, 1994, Benson et al, 1995). Kochkin (2005) estimated that 31.5 million

Americans had hearing loss in 2004, with continued major increases in the baby boomer and

elderly 75 plus age brackets.

Italys population o 57.7 million in 2000 was growing slowly, with deaths exceeding births. Italy

has the lowest population growth rate (1.8% annually) and one o the highest percentages o

elderly citizens in Europe. In 1999, Italy had a ratio o 125 people aged 65 or older to 100 people

aged 14 years or younger, the highest ratio in the European Union. Italian senior citizens over

65 years o age currently represent 18% o the entire population. A key actor that impacts the

uture o the Italian healthcare services sector is the changing demographic proile o the

population (Sistema Statistico Nazionale-Istituto Nazionale di Statistica, 2001).

According to the Italian Sistema Statistico Nazionale-Istituto Nazionale di Statistica (2001), about

15.2 per thousand o Italians have hearing problems. The number o Italians that perceive

diculty hearing increases with age. In addition, there are more Italian men than women who

report hearing problems (15.9 per thousand men against 14. 6 per thousand women). The dierence


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in gender is greater among the elderly (65 to 74 years o age and 75 years o age). Among the

older group (75 years o age), it was ound that 113.9 per thousand o the men against 92.4 per

thousand o the women have hearing loss. From a territorial point o view, the highest population

o Italians who have hearing loss live in the Nord-Oriental region o Italy (19 per thousand) and

the Central region o Italy (17.7 per thousand). Among the regions with a highest level o hearing

loss prevalence, we ind Umbria (24.2 per thousand) ollowed by Emilia Romagna (21.9 per

thousand), Tuscany (21 per thousand) and Friuli Venezia Giulia (21 per thousand).

Gatehouse (2003) stated that the service delivery and the modes o organization utilized to help

people with hearing impairment dier rom country to country and highly depend on the ways

in which healthcare is structured, unded, and delivered.

Healthcare Structure and Hearing Aid Policies in Italy

Martini et al (2001) reported that Italy has a large aging population with a signicant prevalence

o hearing disability and with a great need or rehabilitative services. This situation has caused

an impact in public health planning. According to Lapini et al (2003, p.2), in 1978, Italy established

its current national public healthcare service, Servizio Sanitario Nazionale (National Health

Service), based on the principle o universal entitlement: the state would provide ree and equa

access to care (preventive care, medical care, and rehabilitation services) to all residents

However, ree and universal health care coverage, in conjunction with an aging population,

dramatically increased the use o medical services, thereby increasing healthcare costs. A

process o gradual revision o the original approach took place early on, in an attempt to

regulate demand or services and system o user co-payments was introduced gradually

Health reorms in the early nineties have brought changes to the National Health Service. The

changes increased the unctionality o the Italian Regions causing a reduction o the number

o local health units converting these into Aziende Sanitarie Locali (Local Health Units), which

were to be managed using private sector criteria. Changes were expected to lead gradually

to better services, reduced bureaucracy, and more choice or the patients (Lapini et al, 2003)

Healthcare dissatisaction and an increase in co-payments have created recourse to the

private market or healthcare services. Private accredited institutions provide ambulatory,

hospital treatment and/or diagnosis services nanced by the National Health Service (Lapin

et al, 2003).

The prescription and ees o hearing aids are regulated by the laws o the Ministero di Sanit(Department o Health) and by a document rom 1999 (at the time o this studys completion)

called the Nomenclatore Tariario delle Protesi (Schedule o Rules & Fees or Hearing Aids)

The Nomenclatore Tariario species who has the right to obtain hearing aids, what are the

procedures to obtain hearing aids, what is the classication o the dierent types o hearing

instruments, the criteria or a prescription o a hearing instrument, and the criteria or deductible

ees toward the acquisition o hearing instruments. In Italy, as o the time o this study in 2005

analog basic or very basic digital behind-the-ear analog hearing aids were ree o charge to Italian

citizens.


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However, hearing aids with more than 3 manual controls/trimmers, digitally-programmable,

digital, automatic with noise canceling eatures, directional microphones, all custom-made hearing

aids, and accessories such as remote controls and requency modulated (FM) systems had a

deductible ee. As technology changed ater 2005 there have been some adjustments made to

the regulations o the Nomenclatore Tariario.

Healthcare Structure and Hearing Aid Policies in the United States

The United States healthcare market is driven by reimbursement policies. Health care costs in

the United States are typically covered by managed care groups, private health insurance,

Medicaid/Medicare (through the Health Care Finance Administration), state procurement

agencies and the Department o Veteran Aairs (Bender & Hooper, 2003). The majority o

individuals purchase their own health insurance to receive medical services. Every state has

its own policies and rules. The majority o health insurance policies in the United States do

not cover hearing aids.

Hearing aid cost assistance rom health insurance in the United States and especially or the

elderly is still a much debated issue. In general, the actual cost o hearing aid(s) in the United

States is variable and depends on the type, model, and technology utilized. A survey study

by Cox et al (2003) using the International Outcome Inventory or Hearing Aids (IOI-HA) on 154

elderly subjects, revealed that 65% o the survey takers had paid the entire cost o their hearing

aids. On the other hand, 26.5 % o the survey participants said that hearing aids were partly paid

and 8.5% said that hearing aids were completely paid by a third-party such as private insurance.

Hearing Aid Providers in Italy

Hearing aids in Italy are dispensed by a hearing aid technician or tecnico audioprotesista ater

the device has been prescribed by a medical doctor and authorized by the Local Health Unit

(Azienda Sanitaria Locale). The primary proessional who diagnoses hearing loss and prescribes

hearing aids is the physician, and most likely an otolaryngologist or a medical audiologist.

In addition to the hearing aid technician, there are also audiometric technicians who perorm

hearing evaluations. Audiometric technicians usually perorm hearing tests or the

otolaryngologist. Ater the hearing loss has been diagnosed by the otolaryngologist or

by the medical Audiologist, the prescription or hearing aids is given to the patient. The

patient is then directed to visit the hearing aid technician to obtain the hearing aid(s) and to

be evaluated. Audiometric and Hearing Aid Technicians must obtain a three-year university

diploma that will allow them to practice as audiometrists and as hearing aid dispensers. It is

the responsibility o the hearing aid technician to choose the brand, model, and type o hearing

aid based on the medical prescription. The hearing aid technician must also take the earmold

impressions necessary to obtain the hearing aid(s), counsel the patient, and perorm the hearing

aid evaluation and the ollow ups (Ambrosetti, 2002).


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Hearing Aid Providers in the United States

According to ASHA (1997), the audiologist is the proessional who determines the appropriateness

and design o individual amplication systems. Hearing aid tting is one component o a tota

audiologic, rehabilitation plan. The process o tting hearing aids is composed o assessment

treatment planning, selection, verication, orientation, and validation. In the United States, there

are also hearing aid specialists or dealers (non-audiologists) who have been licensed by their

state to sale/dispense hearing aids to the public.

Most hearing-impaired people who buy hearing aids expect to be tted by a proessional with

expertise. In the United States, an audiologist must have at least a masters degree; however

many audiologists have doctorates too, such as an AuD or a Ph.D degree. Audiologists must be

licensed by their state o residence to practice Audiology and dispense hearing aids. Audiologists

as well as hearing aid specialists must attend seminars and other training events to obtain

continuing education hours and to stay current in order to maintain their licenses. Nowadays

advanced hearing aids require special computer sotware, accessories, and know-how; thereore

experience and skill are undamental to t hearing aids properly.

Cultural Dierences

Cross-cultural research can shed light about possible cultural dierences among elderly candidates

or amplication who do not use hearing aids. Cross-cultural inormation can help us develop an

appreciation or cultural sensitivity and understanding, acknowledge range o diversity in values

and belies about hearing loss/hearing aids, and implement tools that address cultural needs or

achieving hearing successul aid acceptance and use. At the same time, cross-cultural studies

require re-thinking and revision o traditional research methods while designing new methods

o inquiry (Sparks, 2002, p.1).

A cross-cultural study between Americans and Italians by Levin et al (2002), evaluated the

endowment eects and inclusionexclusion dierences in consideration set ormation. The

studys results were discussed in terms o marketing implications and cultural dierences in

emotional reactions to potential losses. Consumers rom both cultures were asked to build up

a basic cheese pizza by either adding components or scaling down rom a ully loaded product

Endowment eects are dened when consumers place greater value on something they already

possess than on something comparable that they do not possess. The authors wanted to

examine which method would lead to a more complete and expensive purchase. There were

two considerations: a) Consumers were allowed to create their own products by either building

up starting with a basic product (basic cheese pizza) and adding desired components (toppings)

with a ully loaded product; or b) Consumers were allowed to scale down starting with a ully

loaded product and removing undesired components (toppings). In addition, they wanted to

know i there was a dierence between the American consumers versus the Italian consumers

Their study revealed that consumers rom both countries ended up with signicantly more

ingredients (toppings) at a higher cost in the scaling down condition. This eect was greater


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or Italians than Americans. Italian consumers elt more loss aversion than Americans. It is

clear that more research is needed to evaluate the generality o dierences in loss aversion and

aect based decision making in dierent cultures

Richard Lewis book When Cultures Collide (2000) provides a global guide to working and

communicating across cultures. Lewis book examines several countries around the world and

classies them within three categories: Linear-actives, Multi-actives, and Reactives (see Figure

1). The United States alls within the Linear-active category while Italy alls within the Multi-active

category. Linear-active cultures preer straightorward and direct discussion, sticking to acts

and gures rom reliable sources, and they are highly organized. Linear-actives partly concea

eelings, value privacy; dislike the maana behavior and over-loquacity, are process oriented,

and their status is gained through achievement. Multi-active cultures are impulsive people who

attach great importance to eelings, relationships, and social interaction. They like animated

communication, speaking and listening all at the same time, interruptions are requent, and

eel uncomortable with silence or pauses. Multi-active cultures are dialogue oriented, ora

communication driven more so than written, emotional and amily-oriented, procrastination

and fexibility is common, gregarious and inquisitive, diplomatic, compassionate and good at

improvisation. Lewis website www.crossculture.com also provides surveys that can help

investigate your own cultural prole. Cross-cultural studies combined with scientic and

market research has the potential to provide useul inormation on similarities and dierences

and modes o decision making across cultures.


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According to Weber et al (2000, p. 2), the rapid globalization o manuacturing, commerce, and

trade, or example, has increased the need or a knowledge base o reliable cross-national dier-

ences in perceptions, belies, or modes o inormation processing. Lewis (2000) has reported

in his book and website that cultural attitudes with regard to science and technology vary in the

general population o dierent cultures. He stated that uture-oriented linear-active cultures

such as the United States accept new technologies more readily while multi-active cultures such

as Italy tend to prioritize people, not machines. From a marketing perspective, the ollowingquestions could be raised: Should hearing aids be proposed dierently to potential candidates

based on cultural backgrounds? Should hearing proessionals ocus on technology eatures or

communication actors during counseling? Does it matter to a specic culture? As technology

changes, we also need to modiy our counseling techniques to help potential hearing aid can-

didates understand the benets o amplication. The knowledge o specic cultural traits could

contribute positively to our approach to audiological counseling as long as it does not become

a stereotyping approach.

The purpose o this study, thereore, was to investigate the ollowing:

1. What are the perceptions o elderly (60 yrs o age) subjects o Italian and

US background (in all subject pools and between group pools) that

complain o hearing loss but do not use hearing aids with regard to:

Benetofhearingaids(Questions1,8,&14)

Cosmetic/physicalappearanceofhearingaids(Questions3,10,&11)

Cost/Valueofhearingaids(Questions5,6,&13)

Socialpressureabouttheuseofhearingaids(Questions2,4,&7).

Whoistheprofessionalproviderforhearingaidservices?(Questions 9, 12, & 15)

2. Are there any dierences in the responses to the surveys with regard to cultural background?

3. What are the uture directions and considerations regarding an improvement o the survey

questions, test-retest reliability and validity?


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METHODS

Instrumentation

The study was conducted through a survey approach (see surveys Appendix) and intended to be

administered in a paper and pencil mode. A 15-item survey called Perceptions about Hearing Aids

rom Non-Users (PHANU) was developed by Beatriz C. Alvarado and veried by two English(American) native speakers. The Italian version o the survey was translated by three Italian

native speakers rom Milan rom the English survey version and rom the Italian survey version

back into English to crosscheck the accuracy o semantics and grammar. The PHANU survey

items were divided in 6 categories: demographic inormation, general perceptions about the

benet o using hearing aids, perceptions about cost o hearing aids, perceptions about cosmetic

appearance, perceptions about seeking help (who is the proessional provider or such services?)

and perceptions about social pressure. One hundred (100) surveys were given per each subject

group in Italy and the United States (projected total=400 surveys). The nal number o surveys

that could be analyzed was 344 (92 surveys or each group in Italy and 80 surveys rom eachgroup in the United States). The surveys were conducted in major cities o each country. The

surveys were distributed or a period o 3 months May 2005 through July 2005. An additiona

3 months and an extra clinical site in the United States were required in order to obtain more

responses.

Subjects & Procedures

The surveys were given randomly to all the subjects who voluntarily agreed to participate by

signing the consent orm and by meeting the subject criteria. The subjects were 60 years o agemale or emale Italian and American who reported diculty hearing but had never used hearing

aids. The subjects were possible candidates or amplication and were divided into two groups

(clinical versus non clinical setting) within each country surveyed. The surveys distributed in

non-clinical settings were mailed to a random list o elderly subjects provided by an association

or the elderly or handed out randomly at an association or the elderly or church senior group

The US non-clinical surveys were distributed in Texas, New York, Minnesota, Illinois, Caliornia

& Florida and the Italy Non-clinical surveys were distributed in Lombardy (Milan, Italy) Condentiality

was assured to all subjects. The subjects participation was recorded by group only. No names

or individual identiying inormation was requested. With the exception o the researcher andassistants involved in running this study, nobody was allowed to see or discuss any o the

individual responses. A brochure about hearing loss and hearing aid inormation was given to

all subjects or participating in the survey.

The ollowing audiologists in the United States administered the surveys and distributed them

in the clinical settings: Lois Sutton, PhD (The Methodist Hospital Audiology Service, Houston,

Texas), Mary Sue Harrison, AuD (Todays Hearing, private practice, Katy, Texas), and Helena

Solodar, AuD (Audiological Consultants o Atlanta, private practice, Atlanta, Georgia). The


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surveys distributed in the clinical settings in Italy were administered by Medical Audiologist,

Dott.ssa Elisabetta Vigliani (Ambulatorio Corso Italia, Milan), by Otolaryngologist/Medica

Audiologist, Dott. Umberto Ambrosetti (Dipartimento di Neuroscienze e Organi dei Sensi

Ospedale Maggiore di Milano, Milan), and by Otolaryngologist/Medical Audiologist, Dott. Domenico

Cuda, (U.O. di Otorinolaringoiatria, Azienda USL di Piacenza, Piacenza).

In the Italian and American clinical settings, the assigned investigator requested permission

ater the audiological assessment had been completed demonstrating candidacy or hearing

aids. The subject had to report at that time that he/she experienced diculty hearing but that

he/she had never used amplication. The subject could or could not have been willing to

pursue amplication at that time. However, the point was that the subject had not used hearing

aids beore. In the non-clinical subject pool, the investigator could only rely on the persons

subjective report o having diculty hearing but I dont use hearing aids because an objective

audiological assessment was not available. However, the subject could have reported that he/

she had a hearing test in the past or recently under demographic inormation. Hearing loss was

dened to be any degree o loss that could be tted with hearing aids and it could be rom mild

mild-to-moderate, mild-to-severe, moderate, moderate-to-severe, or severe degree o hearingimpairment. Proound hearing loss was not included in the criteria because o the limited likelihood

o benet rom hearing aids.

Analysis

The surveys were analyzed using the Rasch Rating Scale Model (Rasch, 1960; 1980; Andrich,

1978; Wright and Masters, 1982). This model can help us transorm raw data rom the human

sciences into abstract, equal-interval scales. Equality o intervals is achieved through log

transormations o raw data odds, and abstraction is accomplished through probabilistic equationsUnlike other probabilistic measurement models, the Rasch Model is the only one that provides

the necessary objectivity or the construction o a scale that is separable rom distribution o the

attribute in the persons it measures (Bond & Fox, 2001, p. 7).

RESULTS

Rasch Rating Scale Model

The 14 items out o 15 items that comprise the Perceptions about Hearing Aids rom Non-Users

(PHANU) scale were analyzed using the Rasch rating scale model (Andrich, 1978; Wright and

Masters, 1982). Item 12 was analyzed separately because Item 12 asked the subjects to choose

rom 4 dierent providers or hearing aid tting services or to choose a not sure answer. Item

12 did not ollow a Likert Scale or rating scale response. All other 14 questions on the survey

were scored in a Likert Scale or rating scale mode. The rating scale model is an extension o the

basic Rasch model (Rasch, 1960; 1980) to polytomous data, which estimates the probability that

a person will choose a particular response category or an item as:


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The Rasch rating scale model produces item calibrations and person measures by converting

the raw scores obtained rom the rating scale into measures that satisy the conditions o order

and additivity required by the interval scale. The item calibrations and person measures are

estimated on a common linear scale, which denes a single latent variable. The unit o measurement

on this scale is the logit which is obtained by a simple logarithmic transormation o the odds

o choosing a particular response category. When the data ts the model, the logit denes an

equal-interval scale, which meets the conditions o order and additivity which allows or the

use o parametric statistics investigations. The common rame o reerence shared by persons

and items acilitates comparisons between and within elements o these two groups. The Rasch

rating scale model allows the researcher to establish a statistical ramework that summarizes

overall rating patterns in terms o group-level main eects or persons and items, and quanties

individual-level eects o the various elements within each group, thus providing diagnostic

inormation about how each individual person and item are perorming.

The Rasch rating scale model also allows or the assessment o the extent to which the data t

the model. When the data ts the model, item calibrations are independent o the samplingdistribution o person measures, and person measures independent o the sampling distribution

o the item calibrations, within standard error. The t o the data to the model is evaluated by t

statistics, which are calculated or both persons and items. The Rasch model provides two indicators o

mist: int and outt. These t statistics have the orm o X2 statistics divided by their degrees

o reedom. The int is sensitive to unexpected behavior aecting responses to items near the

person ability level and the outt is outlier sensitive. Mean square t statistics are dened such

that the model-specied uniorm value o randomness is 1.0. Person t indicates the extent to

which the persons perormance is consistent with the way the items are used by the other

respondents. Item t indicates the extent to which the use o a particular item is consistent withthe way the sample respondents have responded to the other items. For this study, values

between 0.6 and 1.4 are considered acceptable (Wright & Linacre, 1994).

Data were analyzed using the Winsteps (Linacre, 2005) computer program. For each person and

item, the Winsteps computer program provides a measure estimate (in logits), a standard error

(inormation concerning the precision o the measure), and t statistics (inormation about how

well the data t the expectations o the measurement model). Reliability indices are also calculated

or both persons and items.


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Figure 2. Item Map o all Subjects and Positively/Negatively Phrased Item Difculty


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Figure 3.


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Figure 4.


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Table 1. Item Statistics

The distribution o item diculty spans the length o almost three logits (2.94 logits), rom a low

o -1.47 logits to a high o 1.47 logits. The average item diculty is .00 logits (SE = .22). The item

reliability is a high .99, indicating that this 14-item instrument unctions very well. Fit indices

are all within the pre-established bounds o 0.6 to 1.4 suggesting that the data t the model as

expected.

Dierential Item Functioning Analysis

US Clinical vs. US Non-Clinical

The item diculty as perceived by the two dierent groups (US Clinical and US Non-clinical)

was compared using the standardized dierence t-test

The diculty o 10 o the 14 items remained stable

across groups, i.e., both groups endorsed these

10 items at about the same level o diculty.


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US Clinical vs. US Non-Clinical

Four o the 14 items showed signicant dierence between groups. These items are:

Table 2. Item Measure Comparison - US Clinical vs. US Non-Clinical

Item 4 (Negatively Phrased Item)

US clinical respondents ound this item easier to endorse (item diculty = 0.17 logits) than US

non-clinical respondents (item diculty =0.88 logits). The clinical group could have received

counseling about the benets o using a hearing aid and is thereore less susceptible to the

embarrassment actor than the non-clinical group. According to Kiessling (2003, p.20), two

groups o older adult populations with hearing impairment who could benet rom audiologica

rehabilitation are those who seek intervention and those who do not. Kochkin (2005) reported

that some people eel embarrassed because we live in a youth-oriented society where physica

perection is stressed as an ideal human attribute. Acceptance o the hearing loss and the

willingness to try hearing aids with the support o signiicant others can alleviate the

embarrassment actor o acing lie with hearing aids.


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For the US clinical group Item 4 had a total raw score o 168, which is higher than 156 the total

raw score or the US non-clinical group. This means that the clinical group answered the question

with mostly Not at all, which is coded with a 3 or the negatively phrased items. High total raw

scores correspond to low item diculty measures. The non-clinical group answered this question

with mostly Quite a lot/Very much which is coded with a 1 or the negatively phrased items, hence

the lower total raw score. Low total raw scores correspond to high item diculty measures.

Item 8 (Positively Phrased Item)

The US non-clinical respondents ound this item easier to endorse (item diculty = -0.43 logits

than US clinical respondents (item diculty=0.14 logits). The US non-clinical group seems to

be more positive about believing that most people in the US have positive perceptions about hearing

aids. Because the US clinical group was already at the proessionals oce, this could imply

that to some degree they had already accepted that there is a hearing problem. The US clinica

group has received or is in the process o receiving counseling and their opinions about hearing

aids may have taken a dierent perspective. The US clinical respondents are aced with making

decisions about trying hearing aids and thereore may think that other people as a consensus

may be reluctant to use them or have questionable opinions about them.


US clinical respondents ound this item more dicult to endorse (item diculty = 0.69 logits)

than US non-clinical respondents (item diculty =0.22 logits). The clinical group does not

subscribe as readily to the opinion that most people have access to aordable hearing aids

as does the non-clinical group. The clinical group respondents are probably aced with

the reality o paying or the hearing aid and are more aware o restrictive insurance policies

than the non-clinical group respondents, who are perhaps only beginning to recognize that

there is a problem. According to Kochkin (2005), some hearing-impaired people simply

do not have enough income to aord todays advanced hearing aids. Hearing aid costs

become more important to those subjects in the US clinical group than the US non-clinica

group.


US clinical respondents ound this item more dicult to endorse (item diculty = -0.40 logits)

than US non-clinical respondents (item diculty= -0.93 logits). Ater a casual reading o this

item, this may seem surprising. The clinical group, however, seems to have more realistic

expectations about the benets that a hearing aid can provide. Less stress and a better quality

o lie are still goals to be attained, even though hearing diculties are being resolved. The

non-clinical group, who is still very much bothered by hearing aid problems, may still be in the

i I can solve this problem, everything else will be better phase, and hence endorses this item

more readily.


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Italy Clinical vs. Italy Non-Clinical

The item diculty as perceived by the two dierent groups

(Italy Clinical and Italy Non-clinical) was compared using

the standardized dierence t-test. The diculty o 12

out o the 14 items remained stable across groups, i.e.,

both groups endorsed these 12 items at about the same

level o diculty.

Two o the 14 items, however, showed signicant dierence between groups:

Table 3: Item Measure Comparison - Italy Clinical vs. Italy Non-Clinical


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Item 3 (Negatively Phrased Item)

Italy clinical respondents ound this item easier to endorse (item diculty= 0.89 logits) than Italy

non-clinical respondents (item diculty= 1.46 logits). The clinical group had more accepting

perceptions about the cosmetic look reality o hearing aids than the Italy non-clinical group.

The act that the Italy clinical group was surveyed at a clinical setting that can lead us to

believe that the subjects were already seeking help or their hearing problems and thereore had

a more realistic expectation about the aesthetics o hearing aids. On the other hand, item 3 was

more dicult to endorse or the Italy non-clinical group. The Italy non- clinical group subjects

had poorer perceptions about hearing aids in the cosmetic aspect. This nding could be one

o the reasons why these subjects have not obtained hearing aids yet or have not ully

acknowledged their hearing diculties to take the next step.


Italian non-clinical group respondents ound this item easier to endorse (item diculty = -1.20

logits) than Italian clinical respondents (item diculty= -0.60 logits). The signicance o this

item mirrors that o the US non-clinical and US clinical groups ndings. The Italy clinical group

seems to have ewer expectations about the overall benet o hearing aids. Less stress anda better quality o lie are still goals to be attained, even though hearing diculties are being

resolved. The Italy non-clinical group, who is still very much bothered by hearing aid problems

may still be in the i I can solve this problem, everything else will be better phase, and hence

endorses this item more readily.

US Clinical vs. Italy Clinical

Lets now look at the signicant item dierences between the US clinical and the Italy clinical

groups. The diculty o 13 items out o 14 items remained stable across groups. One item

showed a signicant dierence between groups.One item showed a dierence:

Item 4 (Negatively Phrased)

This item was easier to endorse or the US Clinical group (item diculty= 1.7 logits) than or

the Italy Clinical group (item diculty= 0.73 logits). The Italian clinical group seems to be more

concerned about how they will be perceived socially by others compared to the US clinical

group. Communication is extremely important to Italians; they are very talkative and socially

active people. However, aesthetics are also very important. Italians as a culture are known to

be particular about aesthetics. To be seen by others using a hearing aid is a challenge and it

could be stigmatizing to some people. The acceptance and perhaps more amiliar social awareness

about hearing aids by the US clinical group could make a dierence in overcoming eelings o

social embarrassment. An interpretation to this nding could be based on practicality and a

more individualistic view o American society. Italians may eel more embarrassed because

they are araid to be rejected socially by amily and peers. In Italy, it is good to draw attention

to beautiul things but hearing aids may not be considered to be in that category. The Italian

clinical group surveyed is not ready to take the step to obtain hearing aids because o ear o

embarrassment.


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US Non- Clinical vs. Italy Non-Clinical

The item diculty as perceived by the two dierent groups (Clinical and Italy Non-clinical) was

compared using the standardized dierence t-test

The diculty o 12 out o the 14 items remained stable across groups.

US Non-Clinical vs Italy Non-Clinical

Two items showed a dierence:


This item was easier to endorse by the US non-clinical group (item diculty= -0.43 logits) than

the than the Italy non-clinical group (item diculty= .42 logits). The Italy non-clinical group does

not seem to be as optimistic as the US non-clinical group with regard to a collective consensus

on accepting perceptions toward hearing aids by the people in their native country. The moreeducation and awareness o hearing aids by a cultural group, the more likely they are to have an

optimistic view o the potential benets o the technology.


This item was easier to endorse by the US non-clinical group (item diculty= .22 logits) than

the Italy non-clinical group (item diculty= .90 logits). The US non-clinical group believes that

most people in the United States have access to aordable hearing aids compared to the Italy

non-clinical group regarding aordability o hearing aids in Italy. Dierences in the healthcare

structure in both countries can be indicative o this trend. As mentioned earlier, the Italianhealthcare system provides Italian citizens and residents with ree basic analog and economy

digital hearing aids as needed and regulated by the Nomenclatore Tariario. Advanced hearing

aid technology requires a deductible payment rom the potential hearing aid candidate.

Thereore, acquiring advanced hearing aid digital technology has a price or the enduser and

this maybe viewed as an undesired expense. In the United States, healthcare is primarily private

pay and citizens and residents with hearing loss know that obtaining a hearing aid will cost

something. People in the United States are more used to and expect to pay or health related

services including hearing aids. The dierences discussed above were noted between the US

non-clinical and Italy non-clinical groups in each country. It must be kept in mind that the

subjects may or may not know all the details about how much a hearing aid costs. They may

know rom amily, riends, or public inormation. The results cannot be generalized by country

but they can only be attributed to the subject samples surveyed.

Item 12 Analysis

Item 12: Who is the primary health proessional that you would seek in order to be tted with

hearing aids in the United States/Italy?


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Item 12 o the survey was analyzed separately because the answers requested a provider or

hearing aid services; thereore, the answers did not ollow a Rating Scale coding. The

subjects had to select among the ollowing: General Medicine Physician, Audiologist, Hearing

Aid Technician, Otolaryngologist, and Not sure. The survey results showed Audiologist as the

predominant answer among the subjects o the US clinical group and US non-clinical group.

Otolaryngologist was the predominant answer among the subjects o Italy clinical group and

Italy non-clinical group (see Bar graph #1). Secondary to the predominant answers, the Not

sure category was the most utilized in all groups. This nding requires more investigation

and a larger survey sample to validate its interpretation.

According to Traynor (1998), in the United States, audiologists display the best overall credentials

both clinically and proessionally, audiologists are the best qualied to provide hearing aids and

the most cost-eective. On the other hand, Kochkin (1992, p. 13) stated that although one can

argue that the available inormation is not sucient to conclusively prove that audiologists are

Bar Graph 1. Item 12 Responses per Group and Country


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the superior dispensing group, there is little data to suggest that the hearing aid dealer or the

otolaryngologist is superior, or even equal to the audiologist.

Person Measure Comparison

The analysis tested the ollowing hypothesis:

H0: US Clinical = US Non-clinical = Italy Clinical = Italy Non-clinical

H1: At least one mean diers rom the others.

The statistical hypotheses were evaluated via a one-way ANOVA test and a Tukeys post hoc

test.

Conclusions

The Levene test or homogeneity o variance showed that the variances o the our groups can

be considered as not being signicantly dierent (p > .05).

Table 4. Variances

The one-way ANOVA test ound a signicant dierence between the average person measureso the our groups, F (3, 340) = 12.159, p > .001.

To precisely locate the dierence between average person measures, a Tukeys post hoc test was

perormed. The average person measure or the US Clinical group (M = 0.43, SD = 0.83) is

signicantly lower than that o the US Non-clinical group (M = 0.90, SD = 0.96), p > .01. The average

person measure or the US Non-clinical group (M = 0.90, SD = 0.96) is signicantly higher than

that o the Italy Non-clinical group (M = 0.19, SD = 0.70), p > .001, and also than that o the Italy

Clinical group (M = 0.27, SD = 0.84), p > .001. No statistically signicant dierence was ound

between any other pair o average person measures.


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Overall, subjects in the US clinical and non-clinical groups had more accepting perceptions about

hearing aids than the Italian clinical and non-clinical groups. The results indicate that the US

non-clinical group had the highest average person measures compared to all the other groups

(see bar graph #2). This can be interpreted as the US non-clinical group being the subject group

with the highest positive perceptions about hearing aids.

DISCUSSION

The goal o cross-cultural surveys in research is to identiy dierences in response patterns

between populations. From a theoretical perspective, revealed dierences in the surveys items

can provide insights o true scientic value. From a methodological perspective, cross-cultura

surveys can pose challenges that may render direct comparisons between cultural populations

dicult. When a survey such as PHANU is developed, an accurate translation o the survey

items rom one language to another should be obtained careully. PHANU underwent back

to-back translations rom English to Italian and vice-versa to ensure that items were conveying

the same concepts and inormation. The risk o having a poor language translation can result

in measurement bias that can threaten the validity o the ndings as illustrated previously by

Hernvig & Olsens study (2006).


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The application o the Rasch analysis on the PHANU survey items revealed interesting interactions

within and between the US and the IT clinical and non-clinical groups. The US clinical and

non-clinical groups revealed signicant dierences in opinion about hearing aids or questions

regarding social pressure, cost, and benet. The IT clinical and non-clinical groups revealed

signicant dierences in opinion or cosmetic and benet survey questions. The US and IT clinical

groups revealed signicant dierences in opinion about hearing aids with regard to social

pressure aspects. The US and IT non-clinical groups revealed signicant dierences in opinion

about hearing aids with regard to benet and cost. Audiologists were considered the healthcarehearing aid provider according to both US groups while otolaryngologists were the preerred

healthcare hearing aid provider according to both IT groups. The US non-clinical group had the

most positive opinions about hearing aids.

The Rasch rating scale analysis provided valuable inormation about the diculty o the survey

questions, the endorsability o the questions, and the attitude o the subjects with regard to

hearing aids. The Person Item Map o all the subjects revealed that item 5 (Cost) and item 3

(Cosmetic) were the questions most dicult to endorse and item 15 (Provider) was the easiest

to endorse by all subject groups. Overall, PHANUs reliability was high (item= .99 and person

reliability= .67) which demonstrates consistency within and between all subject pool responses

PHANU also demonstrated good validity. The subject responses are well distributed across the

continuum o possible responses but uture utilization o the survey will provide stronger validation.

Future DirectionsOne o the limitations o this survey study relates to its sample size. It is not possible to report

that all US and IT people with the same characteristics as the subjects in this study have parallel

opinions on perceptions about hearing aids as a cultural consensus. The subject sample size

must be very large in order to be able to observe trends or to correlate cultural traits. In orde

to assess i cultural traits correlate with opinions about hearing aids regarding cosmetics, benetand social pressure aspects; questions that evaluate emotions, beauty, social behavior traits

could be included in a revised version o PHANU. Questions about cost o hearing aids and

about who is the provider o hearing aid services depend greatly on the structure o healthcare in

each country; thereore, it is unlikely that cultural traits can reveal much inormation. However,

suggest that PHANU be given in a variety o clinical settings such as hearing aid technician oces

otolaryngologistsoces, medical audiologists oces in Italy and hearing aid specialists/dealers

oces, audiologists oces, and otolaryngologistsoces in the United States. Responses could

shed some light into the opinions o new subjects about who is perceived to be the primary hearing

aid healthcare provider.

Another possible limitation o this study has to do with how some o the PHANU survey questions

were constructed. It would be much easier to score questions that were all positively phrased

or negatively phrased in order to avoid recoding during the analysis. This type o writing can

also benet the subjects response time while lling out the questionnaire. However, it is also

good to maintain a balance between positively and negatively phrased questions in a survey to

maintain randomness across items. According to Rumsey (2003), surveys should avoid the use

o leading questions. Leading questions are questions that are worded in such a way that you

know what the researcher want you to answer.


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Test-retest reliability is an index o score consistency over a short time period (usually a ew

weeks) and indicates how much the individuals normative score is likely to change on near-term

retesting. Score change can be caused by day to day fuctuation in perormance or the individua

recollection o the earlier administration. A test-retest coeicient is a statistical measure

that is obtained by administering the same test twice, with a certain amount o time

between administrations, and then correlating the two score sets. The most important concern

in retesting is whether the individuals retest scores may be infated by the practice eect. The

practice eect depends on the content o the survey questions in this case, and the length o

time or interval or retesting. Due to the experimental design o this survey, it was not possible

to obtain test-retest reliability indexes o score consistency. The surveys were given only once

to each subject to obtain the participants rst impression. This inormation will be collected as

PHANUs questions continue to be evaluated with larger subject samples during uture studies.

Overall, the PHANU survey appears to be a promising tool that could be utilized to provide our

proession with important data that can be o great interest to clinicians, researchers, industry,

and healthcare policymakers. Future directions should implement recommendations on sample

size, cultural trait questions, gender/age/setting variations, and re-wording o the questions tosimpliy its analysis.

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APPENDIX

Instrumentation: Surveys in English and Italian

English Version

Age _______ Gender _________

Have you ever used hearing aids? Yes ______How long ago? _________ No_________

Do you have hearing difculties? Yes______ For how long? _________ No_________

Have you ever had a hearing test? Yes______How long ago? ________No_________

______________________________________________________________________

-IF YOU ARE CURRENTLY USING HEARING AIDS PLEASE DO NOT COMPLETE THE SURVEY.

-IF YOU PERCEIVE HEARING DIFFICULTY BUT YOU DO NOT USE HEARING AIDS PLEASE CONTINUE.

______________________________________________________________________

Please read each item one time, and then indicate your opinion by circling your response. Remember, it is your

FIRST impression that counts. Please CIRCLE ONLY ONE RESPONSE per question. PLEASE DO NOT

LEAVE ANY QUESTIONS BLANK.

1. If you experience hearing difculties, do you believe that hearing aids can truly help you hear well?

Not at all Slightly Moderately Quite a lot Very much

2. Do you feel pressure from your family or friends to use hearing aids?


3. Is the physical size and cosmetic aspect of a hearing aid a very important factor in your decision to obtain one?


4. Do you feel embarrassed because you may draw attention by using a hearing aid?


5. Is cost an important factor in your decision to obtain a hearing aid?


6. Do you think that the cost of a hearing aid is worth it as long as it offers the best technology?

Not worth at all Slightly Moderately Quite a lot Very much

worth it worth it worth it worth it

7. Do you worry about what other people may think of you if they see you ungsi a hearing aid?


8. In general, do you think that in most people in the United States have positive accepting perceptions about

the use hearing aids?



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9. Would you consider obtaining hearing aids if your healthcare provider recommends them?


10. Do you think that it is better to have a small hearing aid even if it can compromise your ability to hear?


11. Do you think that the cosmetic appearance of a hearing aid is not important because to hear

better is more important to you?Not at all Slightly Moderately Quite a lot Very much

12. Who is the primary health professional that you would seek in order to be tted with hearing aids in the

United States?

Physician Audiologist Hearing Aid Otolaryngologist Not sure

General Medicine Technician

13. Do you think that in the United States most people have access to affordable hearing aids?


14. If you experience hearing difculties, do you think that the use of a hearing aid can provide you with less

stress and a better quality of life?


15. If you were to decide to try a hearing aid, is it important to you to obtain a detailed explanation from

your hearing aid

dispenser about the features of hearing aid selected?



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10. Crede che sia meglio avere un apparecchio acustico piccolo anche se questo pu compromettere

la sua capacit di ascolto?

No Leggermente Moderatamente Abbastanza Molto

11. Crede che laspetto estetico di un apparecchio acustico non sia molto importante, perch ascoltare meglio

per Lei pi importante?


12. Quale il primo professionista sanitario che cercherebbe nel caso volesse

utilizzare un apparecchio acustico in Italia?

Medico generico Audiologo Audioprotesista Otorinolaringoiatra Non so

13. Pensa che in Italia la maggior parte delle persone ha accesso agli apparecchi acustici a prezzi ragionevoli?


14. Se sperimenta difcolt di udito, crede che luso di un apparecchio acustico possa darle meno stress

ed una migliore qualit di vita?


15. Se decidesse di provare un apparecchio acustico, importante per Lei ottenere spiegazioni dettagliate dal

fornitore sulle caratteristiche dellapparecchio scelto?


perceptions about hearing aids from elderly non-users: a bicultural point of view (italy & usa)

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