This article is
reprinted with permission from The Hearing Review and
MWC/Allied Healthcare Group, Los Angeles, Sept 2001 (v.
8, no. 9), pgs. 62-67. All rights reserved.
Editor?s Note ? The original article (as published in
the Hearing Review, see above) was a podium presentation
for a professional audience. Due to the importance and
depth of this fine presentation, we have minimally
re-edited this article for the non-professional
audience, to help transfer the knowledge and concepts in
a non-technical manner. We appreciate permission from
Dr. Mark Ross and Mr. Karl Strom, Editor-In-Chief of the
Hearing Review, for allowing us to republish this
important work. --- Douglas Beck, Au.D.,
Editor-In-Chief, Healthy Hearing (www.healthyhearing.com).
INTRODUCTION:
When Geoff Plant asked me to give this keynote
presentation, he said to be sure that I included some of
my personal experiences as a hard of hearing person.
Actually, I wasn?t sure if I could or should do this,
since I don?t feel all that comfortable talking about
myself. On reflection, however, it really may be a good
way to introduce a conference on Aural Rehabilitation
(AR), since I believe there are lessons we can draw for
the present day from my personal experiences a
half-century ago
My hearing loss was detected in l951 while I was in the
Air Force. I think its onset occurred during an earlier
period of military service. Of course, like just anybody
else with hearing loss, I knew I had some hearing
difficulties and, like many other people in the same
predicament, I simply tried to ignore its presence,
getting along as best I could. At the time, the only
help I would have considered would have been medical or
surgical -- some way to "cure" or "fix" my hearing loss.
Fortunately for me, I was not given a choice.
After I was given an audiometric test, which clearly
revealed the presence of hearing loss, the next thing I
knew I was transferred to Walter Reed Hospital, as an
involuntary participant in their AR program. But not
before the examining otolaryngologist told me that I had
"progressive hearing loss" and that I would soon be
going "deaf!"
It was only many years later that I realized the
doctor?s definition of "deaf" and my definition of
"deaf" were quite different. Without hearing aids, I
would indeed be "deaf", but certainly not with them.
From my perspective, the only definition of "deaf" that
counted was my ability to use audition as my primary
communication mode. The fact that I can still do this,
even with a bilateral 90 dB hearing loss, tells me that
I am not functionally "deaf". That doctor did me, and
I?m sure many other patients, a great disservice when he
employed a term in one way that most people would
understand in a different way. Simply said, his comment
scared the hell out of me and this fear stayed with me
for many years, until I learned better.
In any event, the Air Force gave me no opportunity to
object to the transfer, or to engage in the usual and
agonizing self-defeating exercise of denial. Ironically,
it now appears that one of the merits of this entire
process may have been the fact that I did not have a
choice: being in the military, I was simply ordered to
go and I did. In my case, there was not the usual
seven-year delay between the symptoms of a hearing loss
becoming apparent and the acquisition of hearing aids.
Clearly, the military model is not a model we can follow
in civilian life, however we might sometimes wish it.
The Walter Reed AR program lasted for two months, during
which time the participants were all boarded together in
a separate facility. All day every day we went to
various classes, ranging from general information about
hearing loss to speechreading and auditory training. At
the beginning of the program we were issued hearing aids
selected for us by the traditional Carhart procedure (an
early hearing aid selection protocol). We were each
tested with about four to six aids, trying to determine
which one was "best" for us. The measures included
unaided and aided speech discrimination tests in quiet
and in noise, comfort and uncomfortable determinations,
and both use and full gain aided speech reception
threshold (SRT) tests. "Best" was defined in terms of
higher speech discrimination scores, wider dynamic
range, lower aided SRT?s, and subjective preferences.
Cosmetic preferences, as can be imagined, never came up.
This test battery would take almost a complete morning
or afternoon. Even so - that was not the end of the
process. About once a week, I returned for follow-up
testing and such "fine-tuning" as could be done in those
days. Complaints and problems with the hearing aids and
earmolds were handled almost immediately. However, it is
important to note that unlike today, where the provision
of hearing aids is often considered the end point, in my
AR program, the hearing aid was just one component of a
comprehensive AR program.
The formal program was supplemented by many
"bull-sessions" and informal exchanges between and among
clients that took place during, in-between, and after
classes. Although we did not use the term "coping and
communication strategies", that was in essence, what was
going on. We shared our hearing experiences, some of our
feelings (being "macho" young men we didn?t delve too
deeply into ourselves) and examples of what kind of
communication tactics worked and did not work. Actually,
in retrospect, these experiences were probably the most
valuable aspect of the program. The group interactions
provided the kind of emotional support impossible to
replicate in individual counseling sessions. This is
definitely a lesson that we can take to heart even now.
Although we thought we were learning to lip-read and how
to make better use of our residual hearing, and some of
us undoubtedly were, what was also happening was that we
were learning how to accept the hearing loss and accept
ourselves. We would joke with one another about
"being on the air" when we put our hearing aids on and,
by example, encourage those who were reluctant to wear
them. Unlike the pressures new hearing aid users often
feel that can lead to them to discard their hearing aids
? feeling "different", stigmatized and a bit ashamed -
the social climate in the AR program was exactly the
opposite. It was expected that everybody would "conform"
to the accepted practice by regularly wearing his
hearing aids. The fact that the program lasted for two
months made it easier to continue our good hearing aid
habits after we left.
The hearing aids we were issued were monopack vacuum
tube hearing aids, requiring an "A" battery that had to
be changed every two or three days and a "B" battery
that would last a week or two. We felt very lucky to be
the recipients of these "small" convenient instruments,
particularly since the groups who preceded us were
issued duo-pack hearing aids; those required a battery
pack physically separate from microphone and amplifier.
Besides, being in the service, we could hardly insist on
receiving more "cosmetically acceptable" devices. First,
because this kind of demand was simply unheard of in
those days, and second, cosmetic concerns, even if we
could conceive of how far down the ear canal it has
taken us nowadays, was simply not an issue. We wore what
we were ordered to wear, based on professional judgment
regarding what was considered "best" for us. Nowadays,
unfortunately, professional judgment regarding
performance often takes a distant back seat to a
patient?s expressed cosmetic concerns.
After the AR program, I spent three years in the Air
Force, spending much of that time in North Africa where,
I believe, I may have been the only person wearing
hearing aids, if not on the entire continent, at least
in the immediate region. There?s another, very important
lesson, here for the present day: Because I accepted the
fact that I had to wear hearing aids, and accepted
myself on this basis, I truly believe the presence of my
hearing aids was completely irrelevant as far as my work
and social activities were concerned. I didn?t make a
big deal about the fact that I wore hearings aid and
consequently, neither did anyone else. If somebody asked
about it, I simply said it helped me hear like
eyeglasses help someone see. I can?t think of a time
when this explanation did not suffice. I?ve never
accepted the notion that wearing a visible hearing aid
is associated with a negative personal appraisal, some
kind of social stigma invoked by society on hearing aid
users, or what has been termed the "hearing aid effect".
Of course, I do know that some people in our society may
initially judge hearing aid users as less competent and
less desirable, etc. But, I?m convinced that, given
self-acceptance, their attitudes will soon either be
irrelevant or changed. Instead of confronting this
presumed "stigma", however, we pander to it by focusing
on cosmetics rather than performance and need.
I should point out, however, that even with the
exemplary Walter Reed program, I must have still felt a
great deal of uncertainty about how the hearing loss was
going to affect my life. Given the initial diagnosis of
"progressive hearing loss", I was understandably
insecure about the future. When I returned to the U.S.
from North Africa, I asked to be transferred to Walter
Reed hospital so that I could take the AR program once
again. To its credit and to my benefit, the Air Force
agreed to my request.
In a sense, what I was asking for was an AR "booster"
shot. Even more than my first experience, I believe it
was at that time that I truly came to terms with the
fact that I had permanent hearing loss. It was at that
time that I accepted the notion that while its presence
was clearly going to produce some difficulties in my
life, the fact that I was hearing-impaired need not
restrict the course of my life in any fundamental way.
There are lessons we can draw from this for the present
day. Just because we have, or think we have, provided
what we believe to be an appropriate AR program to our
patients, that does not mean that they will thereafter
be "cured" and never darken our doors again. As we well
know, it doesn?t work that way. We know that people?s
hearing loss and their communication needs change over
time. We know that much of what we covered and what we
thought we had resolved initially may have been
forgotten. And we know that new devices and techniques
are constantly being introduced, which may offer
benefits previously unavailable.
Our clients often need a "booster" shot from us, a
provision that should necessitate a routine follow-up
program.
The "Stigma" of Wearing Hearing Aids
Majoring in "Speech and Hearing" when I left the service
brought about a whole new set of lessons that have
stayed with me. Actually, the primary reason I started
college was to learn enough about audition and hearing
aids to be a knowledgeable hearing aid salesman. So for
the first year I was at college I sold hearing aids part
time. In all that time, I sold just one aid, and only
because one of my brothers arranged the sale! I worked
by knocking on the doors of people who had made some
sort of inquiry in the past. Their responses really
exposed me to some of the attitudes about hearing loss
that pervaded our society then and, to a large extent,
now. People would deny they had hearing loss while I had
to shout at them to be heard! Or they would be very
upset that I somehow knew about this terrible secret of
theirs. After all, they were promised when they
responded to an advertisement that they would be sent
material in a plain brown envelope, so nobody would know
they inquired, and that no salesman would come knocking
at their door. And here I was exposing their shame and
stigma for all the world to see!
Salesmen were advised to stress how small and invisible
the hearing aids were. These, we should note, were body
aids! All kinds of tricks were played to minimize
visibility, from transparent tubing that ran from the
earmold to the receiver pinned under the collar, to
beret style aids that were placed in the hair. Fifty
years later, we?re still doing the same thing. It
doesn?t matter how technically advanced hearing aids
have become, or how tiny these really sophisticated
devices are; they?re still not sufficiently invisible
for many people. And for some, they will never be small
enough.
It?s clear that the problem is not the visibility of the
hearing aids, but rather the acceptance of the hearing
loss. In the fifty years that I?ve been involved with
this field, we are still communicating mixed messages.
On one hand, we justifiably stress the technical
advances incorporated in modern hearing aids. At the
same time, however, we emphasize how tiny they are, how
they can fit all the way down in the ear canal and that
nobody "need know they?re wearing hearing aids."
What is happening is that we are reinforcing the very
denial attitudes we are trying to overcome. By stressing
invisibility, we convey the message that there is
something shameful about hearing loss, that it is a
stigmatizing condition that people must disguise as well
as they can. I?m convinced that more potential hearing
aid candidates are discouraged from trying needed
amplification by this type of appeal than are motivated
to try them by the cosmetic arguments. People don?t
"hear" the cosmetic appeal as loudly as they do the
underlying shame and stigma message. If we can?t get
people to acknowledge that they have hearing loss, there
is nothing we can do to help them. Clearly, they are not
ready to help themselves. One measure of our success in
this endeavor would be the percentage of people who can
potentially benefit from amplification who actually wear
hearing aids. In this country, that figure is usually
considered to be about twenty percent - not a very
impressive record.
?
Taking Hearing Loss Seriously
In order for this percentage to increase, there has to
be more awareness
regarding the potential consequences of hearing loss,
that it can, and often does, impact on every aspect of a
person? life. However, instead of some measure of
empathy, what we often get are insensitive comments like
"she can hear if she only pays attention".
If society underestimates, mocks or trivializes the
total impact of hearing loss then it is unlikely that
any type of AR program will be supported or encouraged.
The condition would not be considered a severe enough
public health problem to warrant public resources
allocated to its remediation.
At a time of limited resources and rising expectations,
such an understanding is crucial if AR is to receive its
justified portion of the health-care pie.
If we only had to convince the general public and policy
makers regarding the potential implications of a hearing
loss, and the need for AR services for most people with
hearing loss, then our challenge would be
straightforward, if not easy.
Unfortunately, it seems to me that before we educate
others, we need to start by educating ourselves.
The hearing aid selection and dispensing model most
often employed by hearing aid dispensers focuses on the
instrument - the hearing aid itself, rather than the
person with hearing loss. In the ordinary sequence, a
client first receives an audiological evaluation, then
the hearing aid is selected and several follow-up
appointments are scheduled.
In the current hearing aid dispensing model, the average
total time devoted to all of the activities associated
with the hearing aid acquisition, from the initial
testing and personal interview to the actual selection,
fitting, follow-up and counseling is little more than
two hours (Stika and Ross, 2001). Less than an hour is
spent on the counseling component (Kochkin, l999).
Perhaps the current model provides sufficient time for
these activities. But there certainly will not be time
to deal with other personal and social issues arising
from hearing loss. The current hearing aid dispensing
model implies that all hearing-impaired people need to
correct their problem is an auditory prosthesis, i.e., a
hearing aid. This is clearly not the case.
The fact that people want and need more information can
be seen in the marketing survey prepared for the AAA (Audiology
Today, l998). Almost half the hearing-impaired people
who responded to the survey reported they would have
liked more information on how to select, wear, and care
for hearing aids. About forty percent of them wanted to
learn more about the causes and treatment options for
hearing impairments. Even this relatively high number
probably underestimates the number of people who could
use and benefit from such information.
It is not as if there is any real dispute among
professional audiologists regarding the consequences of
hearing loss. Indeed, there is also an enormous body of
literature on this topic, much too much to review in any
detail here. For example, Carren Stika reported the
results of the many focus groups she conducted with hard
of hearing people and their significant others (Stika,
1997a;l997b). The fact that hearing loss can have a
pervasive and profound effect upon the affected person
and his/her family was clearly demonstrated in this
project.
Implicit in the current hearing aid dispensing models is
the assumption that the provision of hearing aids are
both a necessary and sufficient response to the hearing
loss condition. This model implies that hearing aids can
functionally "cure" the hearing loss and that further
services are either unnecessary or not cost effective.
We would all agree that hearing aids are an absolutely
necessary measure to take in most instances of hearing
loss. However, I would hold that for most people,
hearing aids alone are insufficient.
Of course hearing aids help, and of course most people,
comparing their ability to function with and without
hearing aids, do better with them than without them (Kochkin
& Rogin, 2000). No doubt, many people would believe, at
least initially, their hearing problems have been
"solved" or at least rendered functionally irrelevant by
the hearing aids. Not knowing any better, they accept
less than is possible and live with the resulting
limitations and problems while enjoying the benefits.
This is not good enough. We can do better.
For example, about 16% of people eventually stop wearing
their hearing aids, and a similar number rate their
hearing aid usage as unsatisfactory (Kochkin, 2000).
Satisfaction percentages seem to hover somewhere between
60 and 70 percent. Importantly, we know that additional
counseling and follow-up programs can reduce the number
of returns and increase benefits, use, and satisfaction
rates (reviewed in Ross, 1999; Kochkin, 1999). Indeed, a
number of papers explicitly address the organization,
advantages, and cost effectiveness of AR procedures that
go beyond merely providing hearing aids or cochlear
implants.
?
Services and Information Needed by Hearing Aid Wearers
Let?s consider the services that hearing-impaired people
require when they finally arrive at a hearing center. It
is important to keep in mind that we would not be seeing
these people if their hearing problems had not, somehow,
become personally intolerable or if they had not finally
succumbed to repeated nagging from some significant
other.
What, then, are our professional obligations to them?
The ostensible reason they come to us is for
professional advice regarding hearing aids. And, of
course, the proper selection and instruction in the use
of hearing aids still has to be a paramount
consideration. The implicit reason they see us, however,
is not for hearing aids per se, but because they want
help in minimizing the hearing-related problems they are
experiencing. Well-selected hearing aids are just one
tool, albeit the major one, that addresses this issue.
There are other services and information we can provide
that will help people reduce the total impact of hearing
loss on their lives. The clients may not be aware of
these other services, but shouldn?t it be a professional
responsibility to make these services known to them?
What I am suggesting is a focus not on a product, but on
the rehabilitative process. It is when patients show up
at our door asking for help with hearing aids that we
have the best opportunity to address the totality of
their hearing-related problems. So what services am I
talking about?
- All prospective hearing aid users require a
comprehensive audiologic evaluation. This may sound
self-evident, but what with hearing aids being sold
through mail order and the internet, it cannot be
considered a given. A component of this evaluation
should be devoted to an extensive personal interview.
- Either preceding or immediately following the
personal interview and audiologic evaluation, the
client should have an opportunity to complete some
type of standardized self-assessment scale. The same
scale should be administered after the person has worn
hearing aids for some time. In a recent chapter,
Abrams & Hnath-Chisolm (2000) provide a comprehensive
discussion of outcome measures, with examples of the
different types that can be used for different
purposes. Their rationale extends beyond providing
data regarding therapeutic effectiveness and
institutional accountability. Responses to
self-assessment scales can help guide the nature of
the therapeutic process. ?
- Many, perhaps most, people with hearing loss can
benefit from a group hearing aid follow-up program.
The follow-up program is to supplement, not supplant,
individual counseling. This gives clients an
opportunity to review and share their listening
experiences with other people with hearing loss. The
mutual support people give each other transcends that
which professionals can provide. Some topics, such as
advantages of binaural hearing aids, can be covered
more convincingly when someone else in the group
relates personal experiences, rather than when the
recommendation appears to be tied to a dispenser?s
self interest. Reluctant hearing aid users, or those
who feel that "it is just too much" trouble can be
encouraged appropriately by their peers and
colleagues.
- People need general information regarding the
cause of hearing loss and treatment options. People
deal with problems more effectively when they have a
greater understanding of its nature. Many people come
to clinics wanting and expecting to be "fixed"
medically or surgically. They have to understand why
some types of hearing loss are not amenable to such
treatment and that the best single "treatment" is
often a well-functioning hearing aid.
- People need information about the listening
implications of their own audiometric results (for
example, why so many people seem to be "mumbling", and
why they can often "hear" but not "understand"). This
is the kind of topic that dispensers tend to gloss
over after the 1000th time they explain it
to clients. It is difficult, but necessary to provide
such information each time, as if it were the first
time. ?
- The "significant others" in each person?s life
should understand the communication implications of
their loved one?s hearing loss. By listening to others
make complaints similar to their loved ones, they can
more fully appreciate the problems. One useful
technique is to play a tape of filtered speech to the
normally hearing significant others. ?
- People need information regarding how to care for
their hearing aids and earmolds. They need to know why
one type of hearing aid was selected rather than
another. This leads to a discussion of the particular
features of their own hearing aids, what they do, and
why they were included (e.g. directional microphones,
T-coils, presence or absence of volume controls,
personal FM capability, direct audio input,
multi-bands, multi-memories and so on). This kind of
information takes time to convey and group
presentations can supplement individual instruction. ?
- A group setting lends itself to help people
develop realistic expectations of what hearing aids
can and can?t do. Some people?s expectations may be
unrealistically high, while others set theirs too low.
People have to understand what hearing aids can and
can?t do. This discussion leads naturally to the topic
of other types of hearing assistive devices. ?
- The evaluation and dispensing of other types of
assistive listening devices (ALDs) is, in my
estimation, one of the biggest weaknesses in present
hearing aid dispensing practices. For some people,
specific ALD devices can significantly improve their
quality of life as well as directly impact upon job
performance. Virtually everybody in our society is
required to use a telephone and importantly, telephone
communication can be improved for almost every person
with hearing loss. Virtually everybody watches TV,
goes to the movies, attends lectures or concerts, or
visits houses of worship. In each of these venues, it
is possible to improve listening comprehension with an
assistive listening device. Some people will function
better on the job if they can use a personal FM, a
conference microphone, an amplified telephone, or a
vibrating pager. The need for such devices may not be
immediately apparent; it requires an explicit
evaluation to make this determination.
- People with hearing loss can benefit from
information about various kinds of communication and
repair strategies that can be used to enhance
interpersonal communication. This should include a
presentation and discussion of the basic principles of
speech reading. With a little practice and focus on
the lips and face, hearing-impaired people can improve
their comprehension of the spoken word. They should
know about the concept of assertiveness, when and
where it would be appropriate, and encouraged (via
"homework") to practice it in their everyday lives.
- Finally, even after receiving the services
specified above, many people with hearing loss still
need the continuing support of others in similar
circumstances. The astute audiologist will keep an
open channel to a local chapter of Self Help for Hard
of Hearing People, Inc. (SHHH) and make his/her
clients aware of the potential contribution of this
consumer support group.
Does everybody with hearing loss require all of the
above? Probably not. But we should begin, with the
clinical assumption that anybody who needs hearing aids
to improve communication functioning can benefit from
most of them.
The record in this regard is mixed (Stika & Ross, 2001).
The key limitation is time -and how to find it. It takes
time to listen to our clients and to deal with
communicative, as well as the psychosocial implications
of hearing loss. It takes time to conduct a group
hearing aid orientation program. It takes time to
evaluate the need for and to provide assistive listening
devices. And it takes time, particularly for older
people, to work through hearing aid fitting procedures
until they reach the point that they are receiving the
full benefits of hearing aid amplification. As we keep
hear over and over again, "Time is Money," and
importantly, where do we do find the money to pay for
the time?
?
Redefining the Hearing Aid Selection Procedure
The first thing we have to do, I believe, is change the
way we think about the hearing aid dispensing process.
We can?t rediscover Camelot, the AR program that I
experienced fifty years ago is gone. Like the original
Camelot, it has faded in the mists of time; an
idealistic dream of perfection that we know can never be
recalled. Still, as much as I personally enjoyed and
benefited from the program, I do think much of it was
overkill. When all this began during WW II, there must
have been a great deal of insecurity about what newly
deafened servicemen needed. The decision must have been
to give them everything, growing out of a concern that
otherwise some vital element would be omitted.
We can?t do "everything" nowadays; choices have to be
made. I believe we can do a credible job within the
present system if we incorporate some of the lessons
from the past.
The most important of these lessons is that we must
conceptualize the selection and dispensing of hearing
aids within a larger framework. While it may sound like
a clich?we do have to keep in mind that we are not
working with a pair of ears but with the person to whom
the ears are attached. We should view the hearing aid
fitting as an opportunity to explore a number of
hearing-related issues and to help the hearing-impaired
person deal with them. We must, in brief, redefine the
hearing aid selection process in a way that it routinely
incorporates a multi-session group hearing aid
orientation, or short-term AR, program (Ross, 1999). I
hasten to point out that this is not an original concept
by me; it has been recommended, written about, and
practiced by many of our colleagues, many of whom are
now attending this conference.
I do believe that such a program should not be optional,
but simply be included as a routine component of the
hearing aid dispensing process. For the same reason we
would not think of fitting someone with a hearing aid
unless a prior audiological evaluation was conducted, we
should not fit hearing aids without an organized
follow-up program. This is based on my assumption that
the overwhelming majority of people acquiring hearing
aids for the first time need the kind of services and
information outlined above. By separating these services
from the hearing aid itself, by referring only some of
our hearing aid clients to an organized follow-up
program, we send a message that only exceptional hearing
aid users require and can benefit from such a program.
On the contrary, I believe we should send the opposite
message, that a hearing aid, while certainly the
centerpiece of the aural remediation effort, is only one
of the tools used to reduce the communicative and
handicap impact of hearing loss. What this implies is
that the expenses of the short-term AR program be
included in the cost of the hearing aids (Ross and Beck,
2001).
In summary, our current management model tends to
minimize the total impact of hearing loss. Most people
can use and benefit from the additional services a
short-term aural rehabilitation program can provide.
Such a program can be most efficiently and conveniently
included in association with the acquisition of hearing
aids. In this respect, the lessons from the past are
very clear. If only we "listen" to them.
?
References:
Abrams, H. B. & Hnath-Chisolm, R. (2000). Outcome
measures: The audiologic difference, in Audiology:
Practice Management, Hosford-Dunn, Roseser &
Valente (Eds.) 69-94, Thieme Medical Publishers Inc.:
New York
Abrahamson, J (l997). Patient education & peer
interaction to facilitate hearing aid adjustment.
Hearing Review Supplement, 19-22.
American Academy of Audiology, ?97 AAA Marketing Study,
Audiology ?? Today, 10(1), 10-14.
Kochkin, S. (1999) Paper delivered at the World of
Hearing Conference, May 29, Brussels, Belgium.
Kochkin, S. (2000). MarkeTrak V: "Why my hearing aids
are in the drawer": The consumer perspective", The
Hearing Journal, 53(2) 34-42.
Kochkin, S. & Rogin, C. (2000) Quantifying the obvious:
The impact of hearing instruments on quality of life.
The Hearing Review, 7(1), 6-35.
Ross, M. (1999) Redefining the hearing aid selection
process. Aural Rehabilitation and its
instrumentation, Special Interest Division #7,
American Speech-Language Hearing Association, 7(1), 3-7.
Ross, M. & Beck, D. (2001).Expensive Hearing Aids:
Investing in technology and the audiologist?s time,
article in Audiology Online,
www.audiologyonline.com April 26.
Stika, C. (l997a). Living with hearing loss--Focus group
results: Part I: Family relationships and social
interaction. Hearing Loss, 18(5) 22-28.
Stika, C. (l997b). Living with hearing loss?Focus group
results: Part II: Career developments and work
experiences. Hearing Loss, 18(6), 29-32.
Stika, C. (2001). Results of a hearing aid services and
satisfaction questionnaire, First International Aural
Rehabilitation Conference, Portland, Maine.
Strom, K. E. (2001). An Industry in transformation:
Technology & consolidation lead the field into a new
millennium. The Hearing Review, 8(3), 28-44, 87. |
