perceptions about hearing aids from elderly non-users: a bicultural point of view (italy & usa)
TRANSCRIPT
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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.
Item 13 (Positively Phrased Item)
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.
Item 14 (Positively Phrased Item)
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.
Item 14 (Positively Phrased Item)
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:
Item 8 (Positively Phrased Item)
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.
Item 13 (Positively Phrased Item)
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?
Not at all Slightly Moderately Quite a lot Very much
3. Is the physical size and cosmetic aspect of a hearing aid a very important factor in your decision to obtain one?
Not at all Slightly Moderately Quite a lot Very much
4. Do you feel embarrassed because you may draw attention by using a hearing aid?
Not at all Slightly Moderately Quite a lot Very much
5. Is cost an important factor in your decision to obtain a hearing aid?
Not at all Slightly Moderately Quite a lot Very much
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?
Not at all Slightly Moderately Quite a lot Very much
8. In general, do you think that in most people in the United States have positive accepting perceptions about
the use hearing aids?
Not at all Slightly Moderately Quite a lot Very much
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9. Would you consider obtaining hearing aids if your healthcare provider recommends them?
Not at all Slightly Moderately Quite a lot Very much
10. Do you think that it is better to have a small hearing aid even if it can compromise your ability to hear?
Not at all Slightly Moderately Quite a lot Very much
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?
Not at all Slightly Moderately Quite a lot Very much
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?
Not at all Slightly Moderately Quite a lot Very much
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?
Not at all Slightly Moderately Quite a lot Very much
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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?
No Leggermente Moderatamente Abbastanza Molto
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?
No Leggermente Moderatamente Abbastanza Molto
14. Se sperimenta difcolt di udito, crede che luso di un apparecchio acustico possa darle meno stress
ed una migliore qualit di vita?
No Leggermente Moderatamente Abbastanza Molto
15. Se decidesse di provare un apparecchio acustico, importante per Lei ottenere spiegazioni dettagliate dal
fornitore sulle caratteristiche dellapparecchio scelto?
No Leggermente Moderatamente Abbastanza Molto