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Help-seeking for advanced rehabilitation by adults with hearing loss : an ecological model Dillon Edgett, Lisa Michelle 2002

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H E L P - S E E K I N G F O R A D V A N C E D REHABILITATION B Y A D U L T S WITH H E A R I N G L O S S : AN ECOLOGICAL MODEL by LISA M I C H E L L E DILLON E D G E T T B . S c , Memorial University of Newfoundland, 1991 M . S c , The University of British Columbia, 1995 A T H E S I S S U B M I T T E D IN P A R T I A L F U L F I L M E N T O F THE REQUIREMENTS FOR THE D E G R E E OF DOCTOR OF PHILOSOPHY In THE FACULTY OF GRADUATE STUDIES (School of Audiology and Speech Sciences) We accept this thesis as conforming to the required standard  T H E UNIVERSITY O F BRITISH C O L U M B I A June 2002  © Lisa Michelle Dillon Edgett, 2002  In presenting this thesis in partial fulfilment  of the requirements for an advanced  degree at the University of British Columbia, 1 agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department  or by his or  her  representatives.  It is understood  that copying or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department of  ATidcVTlJ^n ^ Ap^^A  The University of British Columbia Vancouver, Canada Date  DE-6 (2/88)  Shj^AXLQAJ  ii  Abstract H e a r i n g l o s s affects the lives of m a n y i n d i v i d u a l s , m a k i n g c o m m u n i c a t i o n difficult a n d often n e g a t i v e l y i n f l u e n c i n g family, s o c i a l , a n d o c c u p a t i o n a l r e l a t i o n s h i p s , a n d selfi m a g e . T h e a i m of h e a r i n g rehabilitation is t h e r e d u c t i o n of c o m m u n i c a t i o n p r o b l e m s e n c o u n t e r e d by i n d i v i d u a l s with h e a r i n g l o s s . W h i l e participants highly v a l u e g r o u p h e a r i n g rehabilitative p r o g r a m s , t h e r e is a n underutilization of t h e s e rehabilitation services. T h i s s t u d y e x p l o r e s h e l p - s e e k i n g for a d v a n c e d h e a r i n g rehabilitation b y a t t e m p t i n g to a n s w e r the r e s e a r c h q u e s t i o n 'what a r e the f a c t o r s that p r e v e n t or p r o m o t e i n d i v i d u a l s with h e a r i n g l o s s f r o m s e e k i n g a d v a n c e d rehabilitation in the f o r m of g r o u p h e a r i n g rehabilitation'? T w e n t y i n d i v i d u a l s p a r t i c i p a t e d in this s t u d y . S e v e n p a r t i c i p a n t s r e p o r t e d o n p r e v i o u s e x p e r i e n c e with a h e a r i n g rehabilitation p r o g r a m . T h e r e m a i n i n g i n d i v i d u a l s w e r e invited to participate in a p r o g r a m a s part of t h e s t u d y .  Four  participants d e c l i n e d to participate, s e v e n c o m p l e t e d the n i n e - w e e k p r o g r a m , a n d t w o d r o p p e d out b e f o r e t h e p r o g r a m w a s c o m p l e t e d . F o r t h o s e w h o p a r t i c i p a t e d in t h e p r o g r a m , d a t a w e r e c o l l e c t e d b e f o r e , d u r i n g , a n d after the p r o g r a m . S o u r c e s of d a t a i n c l u d e d o n e - t o - o n e interview s e s s i o n s , j o u r n a l e n t r i e s , a n d q u e s t i o n n a i r e s . T h e r e s e a r c h a p p r o a c h f o l l o w e d the p r i n c i p l e s of g r o u n d e d t h e o r y , o n e tradition of qualitative r e s e a r c h . A s y s t e m a t i c a n a l y s i s of the d a t a l e d to a t h e o r e t i c a l f r a m e w o r k . Interview t r a n s c r i p t s a n d j o u r n a l e n t r i e s w e r e c o d e d a n d t h e c o d e s w e r e g r o u p e d into c a t e g o r i e s . F i v e c a t e g o r i e s e m e r g e d f r o m the d a t a : u n d e r s t a n d i n g h e a r i n g l o s s , p e r s o n a l e x p e r i e n c e with h e a r i n g l o s s , interaction b e t w e e n the p e r s o n with h e a r i n g l o s s a n d s o c i e t y , t a k i n g a c t i o n , a n d reflections o n rehabilitation e x p e r i e n c e . E a c h of t h e s e c a t e g o r i e s c o u l d a l s o b e c o n s i d e r e d a s r e s p o n s e s to a d d i t i o n a l q u e s t i o n s that e m e r g e d a s the s t u d y p r o g r e s s e d . T h r o u g h o u t t h e s e c a t e g o r i e s , t h r e e r e c u r r e n t t h e m e s a p p e a r e d : identity, c h a l l e n g e , a n d a d j u s t m e n t . T h e s e t h e m e s a n d c a t e g o r i e s w e r e i n c o r p o r a t e d into t h e d e v e l o p m e n t of the c o r e c a t e g o r y a s a m o d e l of e c o l o g i c a l balance. T h e f i n d i n g s of this s t u d y i n d i c a t e that p a r t i c i p a n t s ' h e l p - s e e k i n g i n v o l v e s a n iterative p r o c e s s w h e r e b y identity is a s s e s s e d , c h a l l e n g e s a r e r e c o g n i z e d , a n d a d j u s t m e n t s a r e m a d e to a d d r e s s t h e c h a l l e n g e s . T h i s m o d e l h a s i m p l i c a t i o n s for a u d i o l o g i c a l p r a c t i c e b a s e d o n the contribution it m a k e s to o u r u n d e r s t a n d i n g of h e l p - s e e k i n g b e h a v i o r for h e a r i n g l o s s , in particular, a n d p o s s i b l y o t h e r h e a l t h i s s u e s m o r e g e n e r a l l y .  Table of Contents Abstract  ii  List of Tables  x  List of Figures  xi  List of Appendices  xii  Acknowledgments  xiii  Chapter 1:  Introduction  1  IDENTIFICATION OF THE PROBLEM  1  T H E PURPOSE OF THIS STUDY THE RATIONALE FOR THIS STUDY RELEVANT THEORETICAL MODELS SUMMARY  3 3 4 5  Chapter 2:  Review of the Literature  OVERVIEW STATEMENT OF THE PROBLEM CONCEPTUAL BACKGROUND  Audiology and Audiologic Rehabilitation  A Historical Perspective Goals of Aural Rehabilitation A Model of Aural Rehabilitation  Relevant Theoretical Models and Frameworks  WHO Model Determinants of Health Health Belief Model Social Learning Theory Social Comparison Theory Transtheoretical Model Coping and Adjustment The Identity Perspective The Ecological Perspective  EMPIRICAL BACKGROUND  The Impact of Hearing Loss  From Impairment to Handicap Activity Participation: Home Participation: Work  Help-Seeking  6 6 6 7  7  8 9 10 13  13 16 17 18 19 20 21 22 24 26  26  26 27 28 29 30  QUALITATIVE RESEARCH  32  RATIONALE FOR APPROACH TO CURRENT STUDY  34  Help-seeking for Hearing Loss Advanced Help-seeking for Hearing Loss  34 35  Chapter 3:  Methods  37  OVERVIEW  37  METHODOLOGICAL CONSIDERATIONS RATIONALE FOR METHODOLOGY  37 40  Research in Audiology Shortcomings of Quantitative Methodology Nature of the Problem Appropriateness of Grounded Theory  40 41 43 43  iv THE STUDY DESIGN  The Site Participant Recruitment Study Participants The Rehabilitation Program T H E STUDY DESIGN: SOURCES OF DATA  Interviews Interviews with the Experienced Group Other Preliminary Interviews Rehabilitation Rejection Interviews Mid-rehabilitation Interviews Post-rehabilitation Interviews Pre-rehabilitation Questions Rehabilitation Class Summaries Course Evaluations Journals Questionnaires Client-oriented Scale of Improvement The Communication Profile for the Hearing Impaired The Readiness to Change Questionnaire Additional Administrations Audiological Results Researcher Notes DATA ANALYSIS STRATEGY  Transcribing Coding Open Coding Axial Coding Developing the Framework GROUP EXPERIENCED  ETHICAL CONSIDERATIONS  Informed Consent Confidentiality 'Off the Record' Comments Personal Experience of the Researcher VALIDITY OF THE RESEARCH  Researcher-participant Relationships Researcher Bias Reactivity Reflexive Thought ASSESSING QUALITY  Auditability Triangulation Transparency of Method SUMMARY  63  63 64 65 67 68  70 77 72 72  73 74 74 74 75  75 76 76 77 77  77 78 78 78  The Participants  EXPERIENCED GROUP  "Robert" "Matt" "Roger" "Kelly" "Ian" "Colleen" "Janet"  49  49 53 54 55 56 57 57 58 58 59 60 60 60 61 61 62 62  70 70  Group Comparisons Memos Themes and Model Development  Chapter 4:  45  45 46 47 49  80 80  80 81 81 82 82 83 84  V  No TO REHABILITATION GROUP "Judy". "Grace" "Hanna". "Ellen" YES TO REHABILITATION GROUP "Claire" "Michelle" "Leslie" "Hillary" "Linda" "Tony" "Derek". DROPOUT GROUP "Cathy" "Gina". Chapter 5:  Theoretical Framework and Results Overview  OVERVIEW COMPARISON OF GROUP FRAMEWORKS THEORETICAL FRAMEWORK THEME DEVELOPMENT CORE CATEGORY SUMMARY Chapter 6:  Understanding Hearing Loss  HEARING Loss HISTORY Time with Hearing Loss Degree of Hearing Loss First Signs Cause Tinnitus and Vertigo Improvement in Hearing Childhood Experiences Testing Prognosis FAMILY HISTORY OF HEARING LOSS COMPARISONS WITH HEARING LOSS Hearing Loss to Hearing Loss COMPARISONS BETWEEN HEARING LOSS AND OTHER DISABILITIES Vision Mobility COMPARISONS OF BELIEFS AND EXPERIENCES Age Attitude Communication Experiences COMPARISONS INVOLVING HEARING AIDS EXPLAINING TO OTHERS Explaining Hearing Loss Explaining Hearing Aids AWARENESS OF OTHERS' HEARING LOSSES TECHNOLOGY: GENERAL Personal Observations Problems Chapter 7:  85 85 86 87 88 89 89 90 92 93 95 96 98 99 99 101 103 103 103 104 104 104 105 106 107 107 108 108 108 109 109 109 110 110 110 111 111 112 112 112 112 113 7 73 113 114 114 115 115 116 116 117 117 117  Personal Experience with Hearing Loss  SELF-PERCEPTIONS Acceptance  119 120 120  vi Denial Assertiveness Awareness of Own Hearing Loss Lifestyle Abilities General Positive Self-perceptions General Negative Self-perceptions DISCLOSURE Purpose Method Process Reasons for Not Disclosing Disclosure about Hearing Aid EMOTIONAL REACTIONS Hearing Loss Communication Difficulties Possible Solutions: Positive Possible Solutions: Negative EFFECT ON COMMUNICATION Desire to Communicate , Inability to Communicate UNDERLYING PERSONAL CONCERNS Voice Safety Humor Function in Social Situations Work IDENTIFICATION OF SPECIFIC PROBLEMS FROM PERSONAL EXPERIENCE Environment: Noise Environment: Other Factors Speaker Listener Message Chapter 8:  Interaction Between the Person with Hearing Loss and Society  EFFECT OF HEARING LOSS ON PERSONAL RELATIONSHIPS Wife Husband Family and Friends Exceptions INFLUENCE OF HEARING LOSS ON LIFESTYLE Change of Activity People Events No Change of Activity People Events Removal From Situation RELATIONSHIPS WITH PROFESSIONALS Doctor ENT Audiologist SOCIAL CONCERNS Work Issues Socialization Issues Advocacy Issues Funding Issues Service Issues Age-related Issues  121 122 122 123 123 124 125 125 125 126 126 127 128 128 128 128 129 129 130 130 130 131 131 131 132 132 133 133 133 133 134 134 135 136 137 137 138 138 140 140 140 140 141 142 142 142 143 143 143 144 144 145 145 146 147 147 148 149  vii Understanding Hearing Loss MISUNDERSTANDINGS BY OTHERS Regarding Not Hearing Regarding Technology STEREOTYPES Towards Hearing Loss Towards Hearing Aids Towards Person with Hearing Loss WORK AND SCHOOL ENVIRONMENTS Work: Details Work: Difficulties School Volunteering Chapter 9:  Taking Action  TECHNOLOGY: USE AND AWARENESS Hearing Aids  History Positive Comments Negative Comments About Two Hearing Aids Expectations Cost Amount of Hearing Aid Use  149 150 150 150 151 151 152 152 153 153 153 154 156 157 158 158  158 159 159 160 160 161 161  Infrared FM  162 162  Loop System Sound Wizard Phone  163 153 163 164 164 165 165 166 166 166 166 167 167 167 167 168 168 168 168 169 169 169 170 170 171 171 171 171 172 172 173  Conference Mic  TTY, VCO, and MRC  Closed Captioning Real-time Captioning Rear-window Captioning Computer/Internet Fax Alerting Devices Cochlear Implant CONVERSATIONAL STRATEGIES Request for Repetition Identification of Topic Anticipating Bluffing Guessing Repeat What Was Heard Specific Suggestions Giving Up STRATEGIES AND SUPPORT Environment Written Material Speechreading Sign Language Vision People Dogs Humor CHHA EarWear  163  Vlll  Chapter 10:  Reflections on Rehabilitation Experience  174  REHABILITATION EXPERIENCE Expectations Positive Comments '. Negative Comments Description General Ear Anatomy Audiograms and Audiogram of Familiar Sounds Factors Affecting Participants' Abilities Hearing Aids and Assistive Listening Devices (ALDs) Pacific Assistance Dog Society (PADS) Working with Hearing Loss Speechreading Assertiveness Relaxation Exercises Comparisons OBSERVATIONS Self Others PARTICIPATION IN THE HEARING REHABILITATION PROGRAM The Decision to Participate in a Program Encouraging Others WhafsNext? DROPPING OUT OF THE REHABILITATION CLASSES POSITIVE CHANGE RESULTING FROM REHABILITATION EXPERIENCE FACTORS AFFECTING PARTICIPATION OF PEOPLE WITH HEARING LOSS Factors Preventing Participation Factors Promoting Participation STUDY REFLECTIONS Journal Positive Effects Negative Effects Chapter 11:  175 175 176 176 177 177 177 178 178 178 179 179 179 180 180 180 181 787 182 183 183 184 184 185 186 187 187 188 188 189 189 790  Contrasting Groups and Comparing Data Sources  191  OVERVIEW CONTRASTING GROUP FRAMEWORKS QUESTIONNAIRE RESULTS Client-oriented Scale of Improvement (COSI) Communication Profile for the Hearing Impaired (CPHI) Readiness to Change Questionnaire for Hearing (RTCQ-H) Questionnaire Summary TRIANGULATION SUMMARY Chapter 12:  191 191 192 192 195 798 799 200 201  Theoretical Development  OVERVIEW CONNECTIONS BETWEEN CATEGORIES IN THE THEORETICAL FRAMEWORK THEMES Identity Understanding Hearing Loss Personal Experience of Hearing Loss Interaction Between Person with Hearing Loss and Society Taking Action Reflections on the Rehabilitative Experience Challenge Understanding Hearing Loss Personal Experience of Hearing Loss  202  :  202 202 204 204 205 206 206 208 208 209 209 210  Interaction Between Person with Hearing Loss and Society Taking Action Reflections on the Rehabilitative Experience Adjustment  Understanding Hearing Loss Personal Experience with Hearing Loss Interaction Between Person with Hearing Loss and Society Taking Action Reflections on the Rehabilitative Experience  CORE CATEGORY SUMMARY Chapter 13:  Discussion  MAJOR CONTRIBUTIONS SIGNIFICANCE Practical Significance Contribution to Audiological Knowledge  Aural Rehabilitation Help-seeking  Theoretical Implications REFLECTIONS ON THE CURRENT STUDY Strengths Limitations DIRECTIONS FOR FUTURE RESEARCH References  ix 210 211 212 213  213 214 214 215 215 216 220 221 221 221 221 226  226 226  227 231 231 233 235 236  X  List of Tables Table 2.1. Goal activities of aural rehabilitation  10  Table 2.2. Categories of coping and their related strategies  21  Table 3.1. Paradigm positions on selected practical issues  38  Table 3.2. Examples of dimensions and codes from Robert's interview  68  Table 3.3. Sample portion of experienced group framework  69  Table 3.4. List of frameworks, as determined by group and information source  70  Table 6.1. Portion of theoretical framework describing theoretical category: Understanding hearing loss 106 Table 7.1. Portion of theoretical framework describing theoretical category: Personal experience with hearing loss 119 Table 8.1. Portion of theoretical framework describing theoretical category: Interaction between the person with hearing loss and society Table 9.1. Portion of theoretical framework describing theoretical category: Taking action  136 157  Table 10.1. Portion of theoretical framework describing theoretical category: Reflections on rehabilitative experience 174 Table 11.1. 'Experienced' group responses to COSI  193  Table 11.2. 'No to rehabilitation' group responses to COSI  193  Table 11.3. 'Yes to rehabilitation' group responses to COSI  194  Table 11.4. 'Dropout' group responses to COSI  195  Table 11.5. Summary COSI data listing difficult listening situations  195  Table 11.6. Average group scores for stages of precontemplation, contemplation, and action, and overall pattern for RTCQ-H 199  xi  List of Figures Figure 2.1. Model for audiologic rehabilitation  11  Figure 2.2. The disablement phenomena as depicted in ICIDH in 1980  14  Figure 2.3. Model of the ICF  15  Figure 2.4. A model of the determinants of health  17  Figure 2.5. Health Belief Model  18  Figure 3.1. Numbers of participants in each of four groups: experienced, no rehabilitation, yes to rehabilitation, and dropout  48  Figure 3.2. Equipment set-up for interview sessions  51  Figure 3.3. Positioning of cameras and interview participants and the resulting split screen image  51  Figure 3.4. An example of the coding process from Robert's interview  66  Figure 5.1. Overview of the model of ecological balance  105  Figure 11.1. CPHI group averages for major category areas and importance ratings at the prerehabilitation administration of the questionnaire 197 Figure 11.2. CPHI group averages for major category areas and importance ratings for post-rehabilitation administration 197 Figure 11.3. CPHI group average estimates by the researcher for major category areas and importance ratings 198 Figure 12.1. Relationship between categories of understanding hearing loss, personal experience with hearing loss, and interaction between the person with hearing loss and society  203  Figure 12.2. Relationship between categories of 'rehabilitation experience' and 'taking action'  203  Figure 12.3. Connection between categories and themes  204  Figure 12.4. Model integrating categories, themes, and core category  217  Figure 13.1. Model of ecological balance: focus on identity  223  Figure 13.2. Model of ecological balance: focus on challenge  224  Figure 13.3. Model of ecological balance: focus on adjustment  224  Figure 13.4. Interaction between the model of ecological balance and existing theoretical models and frameworks 228  xii List of A p p e n d i c e s Appendix A: WIDHH Information  246  Appendix B: Recruitment Notice  247  Appendix C: WIDHH Executive Director Letter of Support  250  Appendix D: Interview Schedule  251  Appendix E: The Rehabilitation Program  252  Appendix F: Core Questions  253  Appendix G: Experienced Interview Questions  254  Appendix H: Preliminary Questions  255  Appendix I: Rehabilitation Rejection Questions  256  Appendix J: Mid-rehabilitation Questions  257  Appendix K: Post Rehabilitation Questions  258  Appendix L: Program Evaluation Form  259  Appendix M: Instructions for Journal Writing  261  Appendix N: Readiness to Change Questionnaire- Hearing  262  Appendix O: Consent Form  263  Appendix P: Video Consent  265  Appendix Q: Theoretical Framework  266  Appendix R: Communication Profile for the Hearing Impaired Data  271  Appendix S: Readiness to Change Questionnaire- Hearing Data  275  xiii  Acknowledgments  T h i s h a s b e e n the m o s t i n c r e d i b l e j o u r n e y , a n d t h e r e a r e m a n y p e o p l e to t h a n k .  I w o u l d like to t h a n k K a t h y P i c h o r a - F u l l e r , m y r e s e a r c h s u p e r v i s o r , m e n t o r , a n d f r i e n d , for p r o v i d i n g a f o u n d a t i o n a n d a d i r e c t i o n , but a l s o e n c o u r a g i n g a n d c h a l l e n g i n g m e to b e i n n o v a t i v e a n d a l w a y s o p e n to n e w i d e a s . T h a n k y o u for b e i n g e n t h u s i a s t i c a b o u t t h e s e d i s c o v e r i e s a n d for h e l p i n g m e to v i s u a l i z e t h e m a s a b e g i n n i n g i n s t e a d of a n e n d . T h a n k y o u for y o u r faith in m y abilities.  I w o u l d like to t h a n k the m e m b e r s of m y s u p e r v i s o r y c o m m i t t e e , M i c h a e l M a c E n t e e a n d G a r y P o o l e , for their e n c o u r a g e m e n t , c h a l l e n g i n g q u e s t i o n s , a n d e x p e r t i s e .  I w o u l d like to t h a n k t h e W e s t e r n Institute for the D e a f a n d H a r d of H e a r i n g a n d its staff for their s u p p o r t , participant recruitment, a n d facilities.  I w o u l d like to t h a n k all the p a r t i c i p a n t s - this w o r k w o u l d not h a v e b e e n p o s s i b l e without t h e m . T h e y m a d e m e both g l a d a n d p r o u d of the w o r k that I d o . T h r o u g h their g e n e r o u s participation, t h e y taught m e t h e i m p o r t a n c e of listening.  I w o u l d like to t h a n k m y f a m i l y a n d f r i e n d s f r o m c o a s t to c o a s t with m a n y points in b e t w e e n - f r o m S t . J o h n ' s , N F to Q u a l i c u m B e a c h , B C - for their s u p p o r t , e n c o u r a g e m e n t , a n d u n d e r s t a n d i n g . A s p e c i a l t h a n k y o u to C h e r r y for h e r e x c i t e m e n t a n d pride in all m y a c c o m p l i s h m e n t s .  F i n a l l y , I w o u l d like to t h a n k m y h u s b a n d , S i m o n E d g e t t . Y o u r o w n w o r k a l l o w e d m e the f r e e d o m to a c c o m p l i s h all that lies in the f o l l o w i n g p a g e s . A s p e c i a l t h a n k y o u for y o u r true effort to u n d e r s t a n d , y o u r p a t i e n c e with m e a n d with this p r o c e s s , y o u r c o m p u t e r a n d t e c h n i c a l e x p e r t i s e , a n d for t a k i n g c a r e of m e . T h i s a c c o m p l i s h m e n t is mine, yours, and ours.  1 C h a p t e r 1:  Introduction  Identification of the P r o b l e m H e a r i n g l o s s affects the lives of m a n y i n d i v i d u a l s , m a k i n g c o m m u n i c a t i o n difficult a n d often n e g a t i v e l y i n f l u e n c i n g family, s o c i a l , a n d o c c u p a t i o n a l r e l a t i o n s h i p s , a n d selfi m a g e . T h e i m p a c t of h e a r i n g l o s s h a s b e e n w e l l d o c u m e n t e d . F o r e x a m p l e , T r y c h i n ( 1 9 9 3 ) identified 12 r e c u r r i n g p s y c h o l o g i c a l i s s u e s for w o r k i n g with a d u l t s w h o a r e h a r d o f - h e a r i n g a n d their f a m i l i e s ; t h e s e w e r e : d e p r e s s i o n , i s o l a t i o n , a n g e r , e x h a u s t i o n , a n x i e t y , insecurity, d e s p a i r , n e g a t i v e s e l f - i m a g e , inability to relax, l o s s of g r o u p affiliation, p a r a n o i a , a n d l o s s of i n t i m a c y .  In a s t u d y c o n d u c t e d by M u l r o w a n d  c o l l e a g u e s ( 1 9 9 0 ) , the i m p a i r e d quality of life a r e a s m o s t a s s o c i a t e d with h e a r i n g l o s s included social, emotional, and communication function. P s y c h o l o g i c a l and somatic d i s t r e s s c a n o c c u r a s a result of c o m m u n i c a t i o n difficulties ( E r i k s s o n - M a n g o l d & C a r l s s o n , 1 9 9 1 ) , a n d a c o g n i t i v e toll c a n a l s o result ( P i c h o r a - F u l l e r & K i r s o n , 1 9 9 4 ) . H e a r i n g l o s s i m p a c t s familial ( M c K e l l i n , 1 9 9 5 ) , o c c u p a t i o n a l (Getty & H e t u , 1 9 9 4 ) , e d u c a t i o n a l ( M c C o r m i c k , P i c h o r a - F u l l e r , P a c c i o r e t t i , & L a m b , 1 9 9 4 ) , s o c i a l , a n d cultural e n v i r o n m e n t s ( M c K e l l i n , 1 9 9 4 ) . In turn, the i m p a c t of all of t h e s e f a c t o r s c a n affect a p e r s o n ' s a p p r o a c h to m a n a g i n g h e a r i n g l o s s a n d the rehabilitative p r o c e s s ( S t e p h e n s , 1996a). T h e r e is a history of r e s i s t a n c e to s e e k i n g h e l p for p r o b l e m s resulting f r o m h e a r i n g l o s s , with i n d i v i d u a l s w a i t i n g a significant a m o u n t of t i m e b e f o r e c o n s u l t i n g a n a u d i o l o g i s t , s c h e d u l i n g a h e a r i n g test, a n d / o r o b t a i n i n g a s s i s t i v e t e c h n o l o g y in the f o r m of h e a r i n g a i d s a n d a s s i s t i v e listening d e v i c e s ( C a r s o n , 2 0 0 0 ; S t e p h e n s , B a r c h a m , C o r c o r a n , & P a r s o n s , 1976; S w a n & G a t e h o u s e , 1990). Hearing rehabilitation  1  is g e n e r a l l y d e f i n e d a s the effort to r e d u c e c o m m u n i c a t i o n  p r o b l e m s e n c o u n t e r e d b y i n d i v i d u a l s with h e a r i n g l o s s . G a g n e ( 2 0 0 0 , p . 6 5 S ) d e f i n e s the g o a l of a u d i o l o g i c a l rehabilitation to b e : "to r e s t o r e or o p t i m i z e participation in activities c o n s i d e r e d limitative by p e r s o n s w h o h a v e a h e a r i n g i m p a i r m e n t o r by o t h e r i n d i v i d u a l s w h o p a r t a k e in activities that i n c l u d e p e r s o n s with a h e a r i n g i m p a i r m e n t " .  The terms "hearing rehabilitation", "audiological rehabilitation", and "aural rehabilitation" will be used interchangeably throughout this document. 1  2 T h r o u g h o u t this d o c u m e n t , a n d for the p u r p o s e of the current s t u d y , h e a r i n g rehabilitation is c o n s i d e r e d to b e a d v a n c e d t h e r a p y , a s it r e a c h e s b e y o n d the h e l p f o u n d through more basic hearing tests a n d conventional hearing aids. G r o u p hearing rehabilitation c o u r s e s m a y i n c l u d e t o p i c s s u c h a s s p e e c h r e a d i n g , a s s e r t i v e n e s s training, g e n e r a l a n d s i t u a t i o n - s p e c i f i c s t r a t e g i e s , v o c a t i o n a l c o u n s e l i n g , s p e e c h c o n s e r v a t i o n , a n d training for c o m m u n i c a t i o n p a r t n e r s ( A b r a h a m s o n , 1 9 9 1 ; A l p i n e r & M c C a r t h y , 2 0 0 0 ; T y e - M u r r a y , 1 9 9 8 ) . H e a r i n g rehabilitation h a s the potential to h e l p m a n y i n d i v i d u a l s by r e d u c i n g the b a r r i e r s to c o m m u n i c a t i o n resulting f r o m h e a r i n g l o s s , but it is a n u n d e r u t i l i z e d c o m p o n e n t of a u d i o l o g i c p r a c t i c e ( P i c h o r a - F u l l e r & S c h o w , 2002). Individuals w h o h a v e c o m p l e t e d g r o u p h e a r i n g rehabilitation p r o g r a m s h a v e e x p r e s s e d the i d e a that all i n d i v i d u a l s with h e a r i n g l o s s s h o u l d participate in s u c h a p r o g r a m ; s o m e i n d i v i d u a l s b e l i e v e that rehabilitation p r o g r a m s s h o u l d b e i n c l u d e d in s e r v i c e s a s s o c i a t e d with the p u r c h a s e of a h e a r i n g a i d . D e s p i t e the e x p r e s s e d e n t h u s i a s m , m a n y of the rehabilitation ' g r a d u a t e s ' a d m i t t h e r e w a s a t i m e w h e n t h e y w e r e not ' r e a d y ' to participate in s u c h a g r o u p . T h i s o b s e r v a t i o n of d e l a y e d h e l p s e e k i n g for a d v a n c e d rehabilitation, f r o m m y p e r s o n a l e x p e r i e n c e a s a rehabilitative a u d i o l o g i s t , w a s a l s o c o n f i r m e d b y Israelite a n d J e n n i n g s ( 1 9 9 5 ) a n d B a c k e n r o t h a n d A h l n e r ( 2 0 0 0 ) . W h a t m a k e s s o m e i n d i v i d u a l s f e e l t h e y a r e r e a d y to p a r t i c i p a t e ?  What  f a c t o r s w o u l d m a k e m o r e clients w a n t to p a r t i c i p a t e ? W h a t d o c l i e n t s g a i n f r o m participating in g r o u p h e a r i n g rehabilitation p r o g r a m s ? A r e t h e r e clients w h o a r e not helped by t h e s e p r o g r a m s ? T h e r e a r e a n u m b e r of p o s s i b l e r e a s o n s w h y t h e s e s e r v i c e s a r e u s e d b y a s m a l l n u m b e r of p e o p l e w h o a r e h a r d - o f - h e a r i n g .  In addition to the p s y c h o l o g i c a l a n d p s y c h o -  s o c i a l f a c t o r s s u g g e s t e d a b o v e , the field of a u d i o l o g y likely c o n t r i b u t e s to s u c h u n d e r u t i l i z a t i o n . A u d i o l o g i s t s a r e u n s u r e w h o is a n a p p r o p r i a t e c a n d i d a t e for a rehabilitation p r o g r a m . A s w e l l , m a n y a u d i o l o g i s t s d o not i n c l u d e g r o u p rehabilitation s e s s i o n s a s a f a c e t of their j o b d e s c r i p t i o n , a n d t h e r e is a s h o r t a g e of rehabilitation a u d i o l o g i s t s ; in fact, C a r m e n a n d T y e - M u r r a y ( 2 0 0 0 , p.36) report that " a u r a l rehabilitation h a s r e m a i n e d a rather e l u s i v e c o m p o n e n t of p r a c t i c e for m o s t h e a r i n g h e a l t h c a r e practitioners".  C o n s e q u e n t l y , potential clients m a y b e u n a w a r e of the  possibility of h e a r i n g rehabilitation, or t h e s e p o s s i b i l i t i e s m a y not b e a v a i l a b l e .  The Purpose of this Study  3  The primary research question of this study was: What are the factors that promote and prevent individuals with hearing loss from seeking advanced rehabilitation in the form of group hearing rehabilitation? Additional research questions emerged through the course of the study. These supplementary questions, which ultimately became the categories of the framework, were: How do individuals who are hard-of-hearing understand their hearing loss? What is the personal experience of living with hearing loss? What are the social implications of living with hearing loss? What can individuals do to cope with hearing loss? What are the implications of participating in a hearing rehabilitation program? By identifying the factors that promote and prevent individuals from seeking advanced rehabilitation, the first practical aim of the proposed research is to contribute to an improvement in audiologic services. Understanding these factors will better enable audiologists to appropriately recommend and deliver more effective hearing rehabilitation services to a greater number of individuals. The proposed research may benefit the community of people who are hard-of-hearing by suggesting how to improve access to rehabilitation services and, in turn, reducing communication barriers resulting from hearing loss. A second equally important and complementary issue is to provide audiologists with the information needed to determine which clients are not yet ready, or which clients do not need rehabilitation classes as a component of their audiological service. It is expected that this research will help audiologists to determine which clients are ready to participate in group rehabilitation sessions. The Rationale for this Study The purpose of this study was to explain why some people seek help through group hearing rehabilitation programs, while others do not seek this support. Group rehabilitation classes for individuals who are hard-of-hearing are presumed to reduce the communication barriers resulting from hearing loss and reduce the handicapping effects of hearing loss that are experienced in social, familial, educational, and occupational environments. These classes aim to help individuals regain control over their communicative experiences by increasing personal skills and raising confidence, awareness, and knowledge. A very small percentage of those who seek help through  h e a r i n g t e s t s or h e a r i n g a i d s c o n t i n u e their s e a r c h for a d v a n c e d rehabilitation opportunities. T h e r e is a p a u c i t y of e m p i r i c a l a n d t h e o r e t i c a l w o r k s that illuminate t h e a s s u m p t i o n s that h a v e b e e n m a d e a b o u t the n e e d for a n d u s e f u l n e s s of a d v a n c e d a u d i o l o g i c a l rehabilitation. M o r e s p e c i f i c a l l y , t h e r e a r e o n l y a s m a l l n u m b e r of s t u d i e s in the a u d i o l o g y literature that a d d r e s s h e l p - s e e k i n g for h e a r i n g l o s s (for i n s t a n c e , s e e M a h o n e y , S t e p h e n s , & C a d g e , 1 9 9 6 ; S w a n & G a t e h o u s e , 1 9 9 0 ; v a n d e n Brink, Wit, K e m p e n , & van H e u v e l e n , 1996). F e w e r studies have e x a m i n e d help-seeking i s s u e s t h r o u g h a qualitative a p p r o a c h ( s e e C a r s o n , 2 0 0 0 ; G e t t y , G a g n e , & M c D u f f , 1 9 9 6 ) . H o w e v e r , the current s t u d y is u n i q u e in its qualitative f o c u s o n a d v a n c e d h e l p - s e e k i n g t h r o u g h rehabilitation p r o g r a m s . It s p e c i f i c a l l y a d d r e s s e s the d i s c r e p a n c i e s that m a k e this p r o b l e m interesting. Importantly, t h e r e is a d i s c r e p a n c y b e t w e e n the l o w proportion of i n d i v i d u a l s s e e k i n g h e l p t h r o u g h g r o u p h e a r i n g rehabilitation p r o g r a m s , a n d t h e a p p a r e n t e x c i t e m e n t , s a t i s f a c t i o n , a n d e a g e r n e s s to r e c o m m e n d t h e s e p r o g r a m s b y individuals w h o have completed t h e m . T h i s is a qualitative s t u d y , w h i c h will c a p t u r e different p e r s p e c t i v e s f r o m p a r t i c i p a n t s ; s o m e p a r t i c i p a n t s h a v e prior e x p e r i e n c e with h e a r i n g rehabilitation p r o g r a m s . O t h e r participants c h o s e to participate in a g r o u p h e a r i n g rehabilitation p r o g r a m a s a part of the s t u d y , w h i l e o t h e r s did not. T h i s r e s e a r c h s t u d y h o p e s to p r o v i d e v a l u a b l e insights that c a n i m p r o v e t h e e x p e r i e n c e s of i n d i v i d u a l s with h e a r i n g l o s s , b r o a d e n a u d i o l o g y s e r v i c e s by u n d e r s t a n d i n g the f a c t o r s that affect the u n d e r u t i l i z a t i o n of g r o u p h e a r i n g rehabilitation p r o g r a m s , a n d s u p p l e m e n t current literature in a u d i o l o g y , h e l p - s e e k i n g , a n d health psychology. Relevant Theoretical Models M o d e l s a n d t h e o r e t i c a l f r a m e w o r k s f r o m s e v e r a l a r e a s will b e c o n s i d e r e d . A m o d e l of a u d i o l o g i c a l rehabilitation ( S c h o w & N e r b o n n e , 2 0 0 2 ) , a n d m o d e l s f r o m r e l a t e d f i e l d s concerning health beliefs (Becker, 1974; B e c k e r & M a i m a n , 1975; E v a n s & S t o d d a r d , 1 9 9 0 ) a n d the c o n s e q u e n c e s of a h e a l t h c o n d i t i o n ( W H O , 2 0 0 1 ) will p r o v i d e a n u n d e r s t a n d i n g of h e a l t h b e h a v i o r s . T h e o r i e s relating to identity ( G o f f m a n , 1 9 6 3 ) , s o c i a l learning (Bandura, 1986) and social c o m p a r i s o n (Festinger, 1954), coping a n d a d j u s t m e n t ( L a z a r u s & F o l k m a n , 1 9 8 4 ; M o o s , 1 9 8 6 ) will p r o v i d e a g r e a t e r  5 u n d e r s t a n d i n g of h e l p - s e e k i n g b e h a v i o r s . E a c h of t h e s e t h e o r e t i c a l f r a m e w o r k s will b e d i s c u s s e d a n d related to the current r e s e a r c h . Summary T h i s c h a p t e r i n t r o d u c e d the p r o b l e m s that c a n f a c e i n d i v i d u a l s with h e a r i n g l o s s a n d the underutilization of g r o u p h e a r i n g rehabilitation p r o g r a m s . It a l s o d e s c r i b e d t h e p u r p o s e a n d rationale for the current s t u d y , a n d it i n t r o d u c e d literature to s u p p o r t the s t u d y . A m o r e c o m p r e h e n s i v e literature r e v i e w is p r e s e n t e d in the next c h a p t e r .  6 C h a p t e r 2:  Review of the Literature  Overview T h e p u r p o s e of this c h a p t e r is to r e v i e w the literature r e l e v a n t to the current s t u d y : a d v a n c e d h e l p - s e e k i n g for a d u l t s with h e a r i n g l o s s t h r o u g h g r o u p h e a r i n g rehabilitation p r o g r a m s . T h e c o n c e p t u a l i s s u e s relevant to the r e s e a r c h q u e s t i o n will b e d i s c u s s e d , i n c l u d i n g the e v o l u t i o n of a u d i o l o g i c a l p r a c t i c e a n d the e c o l o g i c a l f r a m e w o r k for u n d e r s t a n d i n g the d i m e n s i o n s of d i s a b l e m e n t a n d f u n c t i o n i n g . A n e m p i r i c a l r e v i e w of the r e l e v a n t r e s e a r c h c o n c e r n i n g the c o n s e q u e n c e s of h e a r i n g l o s s will b e p r e s e n t e d , a n d m e t h o d o l o g i c a l c o n s i d e r a t i o n s will b e a d d r e s s e d . T h i s c h a p t e r will c l o s e with a p r e s e n t a t i o n of the r a t i o n a l e for the current s t u d y . S t a t e m e n t of t h e P r o b l e m H e a r i n g rehabilitation p r o g r a m s a i m to r e d u c e the difficulties e x p e r i e n c e d by i n d i v i d u a l s with h e a r i n g l o s s . H o w e v e r , g r o u p p r o g r a m s a s a f o r m of h e a r i n g rehabilitation a n d , i n d e e d , a u d i o l o g i c a l c o n s u l t a t i o n in g e n e r a l , a r e c o n s i d e r e d by m a n y to b e u n d e r u t i l i z e d ( S c h o w & N e r b o n n e , 2 0 0 2 ) . E v i d e n c e s h o w s that m a n y p e o p l e wait a significant a m o u n t of t i m e b e f o r e c o n s u l t i n g a p r o f e s s i o n a l for h e a r i n g l o s s ( C a r s o n , 2 0 0 0 ; S w a n & G a t e h o u s e , 1990). A s well, F r a n k s (1985) and K o c h k i n (1992) h a v e s h o w n that i n d i v i d u a l s a l s o p o s t p o n e o b t a i n i n g a p p r o p r i a t e a m p l i f i c a t i o n d e v i c e s . T h e current s t u d y f o c u s e s o n a n o t h e r s t e p in the rehabilitative p r o c e s s , n a m e l y g r o u p h e a r i n g rehabilitation p r o g r a m s that f o c u s o n a s p e c t s o t h e r t h a n h e a r i n g i n s t r u m e n t fitting a n d orientation. S u c h p r o g r a m s typically i n c l u d e s p e e c h r e a d i n g , a s s e r t i v e n e s s training, a n d f a c t o r s that affect the ability to h e a r a n d s p e e c h r e a d (e.g., A b r a h a m s o n , 1991; Alpiner & McCarthy, 2000; Pichora-Fuller & S c h o w , 2002; Tye-Murray, 1998). T h e current s t u d y a t t e m p t s to a d d r e s s the i s s u e of underutilization of a d v a n c e d rehabilitation p r o g r a m s by identifying t h e f a c t o r s that p r e v e n t a n d p r o m o t e a d v a n c e d h e l p - s e e k i n g for h e a r i n g l o s s in the f o r m of g r o u p h e a r i n g rehabilitation p r o g r a m s . A d i s c u s s i o n of i s s u e s r e l e v a n t to a u d i o l o g i c rehabilitation, a m o d e l that d i s c u s s e s t h e c o n s e q u e n c e s of h e a l t h c o n d i t i o n s , a n d t h e o r i e s of h e a l t h b e l i e f s , b e h a v i o r c h a n g e , c o p i n g , a n d a d a p t a t i o n a r e p r e s e n t e d a s p o s s i b l e s u p p o r t for u n d e r s t a n d i n g this i s s u e . H o w e v e r , a s p r o p o s e d by g r o u n d e d t h e o r y m e t h o d s to r e d u c e i m p o s i t i o n of e x i s t i n g t h e o r e t i c a l v i e w s , the literature r e v i e w w a s c o m p l e t e d after t h e d a t a c o l l e c t i o n w a s  c o m p l e t e a n d the a n a l y s i s w a s c o n c l u d e d . T h i s c h a p t e r a l s o p r e s e n t s r e s e a r c h f i n d i n g s that d o c u m e n t the i m p a c t of h e a r i n g l o s s a n d further s u p p o r t the r e l e v a n c e a n d n e e d for the current s t u d y . Conceptual Background T h i s s e c t i o n will d e s c r i b e the e v o l u t i o n of a u d i o l o g y a s a p r o f e s s i o n a n d rehabilitative a u d i o l o g y a s a s p e c i a l t y field. T h e W o r l d H e a l t h O r g a n i z a t i o n I C F m o d e l ( W H O , 2 0 0 1 ) will b e u s e d a s a f r a m e w o r k to o r g a n i z e the d e s c r i p t i o n of rehabilitative a u d i o l o g y .  To  c o m p l e t e the c o n c e p t u a l f o u n d a t i o n for the current s t u d y , the s e c t i o n will a l s o d e s c r i b e r e l e v a n t t h e o r i e s of health beliefs, b e h a v i o r c h a n g e , c o p i n g , a n d a d a p t a t i o n . Audiology and Audiologic Rehabilitation A u d i o l o g y i n v o l v e s the s t u d y of h e a r i n g a n d h e a r i n g d i s o r d e r s ; its g o a l is the identification of h e a r i n g i m p a i r m e n t , m e a s u r e m e n t of the i m p a i r m e n t , a n d rehabilitation of t h o s e with the h e a r i n g i m p a i r m e n t ( N e w b y & P o p e l k a , 1 9 9 2 ) . A distinction is often m a d e b e t w e e n a u d i o l o g i s t s w h o d i a g n o s e a h e a r i n g l o s s a n d t h o s e w h o f o c u s o n the rehabilitation n e e d s of the i n d i v i d u a l . A p a r a d i g m shift ( K u h n , 1 9 7 0 ) h a s e m e r g e d in a u d i o l o g y a n d significant c h a n g e s a r e o c c u r r i n g in all a r e a s of the field. D i a g n o s t i c t e s t s h a v e p r o g r e s s e d f r o m d e l i b e r a t e w h i s p e r s a c r o s s a r o o m a n d t e s t s p e r f o r m e d with t u n i n g f o r k s that emitted o n e of a f e w a v a i l a b l e f r e q u e n c i e s . E x p e r i m e n t a t i o n with e l e c t r i c a l h e a r i n g - t e s t i n g d e v i c e s w a s c o n d u c t e d in the n i n e t e e n t h c e n t u r y a n d led to the first prototype of the m o d e r n a u d i o m e t e r in the 1 9 2 0 ' s ( N e w b y & P o p e l k a , 1 9 9 2 ) . T h i s t e c h n o l o g i c a l a d v a n c e w a s the p r e c u r s o r to w h a t w o u l d b e c o m e a d i v i s i o n in the field of a u d i o l o g y . A c c o r d i n g to H u l l : " A s i n s t r u m e n t a t i o n b e c a m e m o r e e l a b o r a t e d u r i n g the 1 9 5 0 s a n d particularly d u r i n g the 1 9 6 0 s , a n d the field b e c a m e m o r e s o p h i s t i c a t e d in the a r e a of r e s e a r c h , a shift of e m p h a s i s t o w a r d p u r e a n d a p p l i e d r e s e a r c h a n d in the d i a g n o s i s of site of l e s i o n of a u d i t o r y d i s o r d e r s in m e d i c a l e n v i r o n m e n t s b e c a m e e v i d e n t . It w a s a p p a r e n t that the e m p h a s i s a m o n g the majority of p r o f e s s i o n a l s a n d training p r o g r a m s w a s turning toward d i a g n o s i s , instrumentation, a n d r e s e a r c h and a w a y from aural rehabilitation. R e s u l t s f r o m a n a u t o m a t e d p i e c e of e q u i p m e n t or f r o m a r e s e a r c h project w e r e m o r e t a n g i b l e t h a n the e m e r g i n g s i g n s of i m p r o v e m e n t in s o c i a l c o m m u n i c a t i o n o b s e r v e d in a n adult client w h o w a s h e a r i n g i m p a i r e d . " (Hull, 1 9 9 2 , p.9)  8  T h i s v i s i o n a r y d i s c r e p a n c y r e m a i n s in a u d i o l o g y t o d a y . S o m e a u d i o l o g i s t s v i e w a u r a l rehabilitation a s a n attempt to r e d u c e both the c o m m u n i c a t i o n b a r r i e r s that exist a s a result of the h e a r i n g i m p a i r m e n t a n d the p s y c h o l o g i c a l i m p a c t of the i m p a i r m e n t . A s s e s s m e n t of the h e a r i n g i m p a i r m e n t c a n b e a n important first s t e p in the rehabilitation p r o c e s s . H o w e v e r , o t h e r s h a v e u s e d a s s e s s m e n t a s the o n l y s t e p in this p r o c e s s , effectively d i s r e g a r d i n g t h e r a p e u t i c efforts.  M a n y g a i n s h a v e b e e n m a d e to d e c r e a s e  the gulf that e x i s t s b e t w e e n t h o s e p r o m o t i n g a u r a l rehabilitation a n d t h o s e p r o m o t i n g t e c h n o l o g y ; h o w e v e r , s o m e c l i n i c i a n s a r e not c o n v i n c e d of the benefits of a u r a l rehabilitation.  U n f o r t u n a t e l y , " a u r a l rehabilitation h a s b e e n r e l e g a t e d to s e c o n d a r y  s t a t u s , c a r r y i n g l e s s p r e s t i g e , r e c o g n i t i o n , a n d a w a r d s " ( R o s s , 1 9 9 7 , p. 11). T h e e c o n o m i c i n f l u e n c e o n a u d i o l o g i c a l s e r v i c e s differs in C a n a d a , the U n i t e d S t a t e s , E u r o p e , a n d A u s t r a l i a ; m o n e t a r y c o v e r a g e for a u d i o l o g i c a l s e r v i c e s v a r i e s to a g r e a t d e g r e e e v e n within C a n a d a .  It is important to r e c o g n i z e the i m p a c t of t h e s e s o c i a l a n d  e c o n o m i c f a c t o r s o n a u d i o l o g i c p r a c t i c e . C o n s u m e r i s m h a s f l o u r i s h e d , a n d the f o c u s o n s e l l i n g d e v i c e s h a s d r i v e n the e v o l u t i o n of a u d i o l o g i c p r a c t i c e ; private a n d p u b l i c parties p a y for, or partially p a y for, h e a r i n g a i d s a s a n a c c u s t o m e d s t a n d a r d . H o w e v e r , the d e v e l o p m e n t a n d e x e c u t i o n of rehabilitation p r o g r a m s h a s l a g g e d d u e to political a n d e c o n o m i c f a c t o r s ; c o v e r a g e of a d v a n c e d rehabilitation s e r v i c e s a r e not p r o v i d e d by third-party i n s u r e r s , a n d private p a y m e n t is difficult for m a n y i n d i v i d u a l s . A Historical Perspective T h e historical o r i g i n s of the p r o f e s s i o n of a u d i o l o g y a n d the clinical s p e c i a l t y of a u r a l rehabilitation a r e m u c h m o r e intertwined t h a n their p r e s e n t d a y r e l a t i o n s h i p w o u l d s u g g e s t . A l t h o u g h t h e r e w e r e i n d i v i d u a l s w o r k i n g with p e o p l e with h e a r i n g l o s s before the 1 9 4 0 s , the p r o f e s s i o n a l field of a u d i o l o g y in N o r t h A m e r i c a d e v e l o p e d rapidly a r o u n d t h e t i m e of W o r l d W a r II ( N e w b y & P o p e l k a , 1 9 9 2 ; S c h o w & N e r b o n n e , 2 0 0 2 ) , w h e n s e r v i c e m e n a n d w o m e n w h o s u f f e r e d s e r i o u s h e a r i n g l o s s e s d u e to n o i s e e x p o s u r e o r h e a d injury w e r e returning f r o m the w a r . T h e military a u r a l rehabilitation p r o g r a m s that w e r e d e v e l o p e d in the U n i t e d S t a t e s to h e l p t h e s e i n d i v i d u a l s p r o v i d e d the b i r t h p l a c e of N o r t h A m e r i c a n a u d i o l o g y (Hull, 1 9 9 2 ) , a n d they laid the f o u n d a t i o n for the p r o f e s s i o n that w o u l d b e c o m e r e s p o n s i b l e for the identification a n d m e a s u r e m e n t of h e a r i n g l o s s a n d the rehabilitation of t h o s e with h e a r i n g i m p a i r m e n t s . T h i s n e w p r o f e s s i o n of a u d i o l o g y w a s first d e s c r i b e d in 1 9 4 6 , a n d R a y m o n d C a r h a r t , w h o  9 p i o n e e r e d in the a u d i o l o g i c rehabilitation of W W I I s e r v i c e m e n , h e l p e d n a m e the p r o f e s s i o n a n d s t a r t e d t h e first training p r o g r a m for a u d i o l o g i s t s . Efforts to p r o v i d e rehabilitation to i n d i v i d u a l s with h e a r i n g l o s s , h o w e v e r , h a v e e x i s t e d m u c h longer; P e d r o P o n c e d e L e o n of S p a i n h a s b e e n r e p o r t e d to b e the first t e a c h e r of t h o s e with h e a r i n g l o s s a s e a r l y a s the 1 5 0 0 s ( S c h o w & N e r b o n n e , 2 0 0 2 ) . G o a l s of A u r a l R e h a b i l i t a t i o n T y e - M u r r a y ( 1 9 9 8 , p.2) d e f i n e s a u r a l rehabilitation a s "intervention a i m e d at m i n i m i z i n g a n d a l l e v i a t i n g t h e c o m m u n i c a t i o n difficulties a s s o c i a t e d with h e a r i n g l o s s " . W h i l e S c h o w a n d N e r b o n n e ' s definition of a u r a l rehabilitation is c o m p a r a b l e , t h e y a l s o s p e c i f y that a u r a l rehabilitation d o e s n ' t not follow a strict m e d i c a l m o d e l , but is a p r o c e s s " d e s i g n e d to c o u n s e l a n d w o r k with p e r s o n s w h o a r e d e a f a n d h a r d - o f - h e a r i n g s o that t h e y c a n a c t u a l i z e their o w n r e s o u r c e s in o r d e r to m e e t their u n i q u e life s i t u a t i o n s " ( S c h o w & N e r b o n n e , 2 0 0 2 , p.4). Important c o n s i d e r a t i o n s in the p l a n n i n g , a p p l i c a t i o n , a n d e v a l u a t i o n of the o u t c o m e s of h e a r i n g rehabilitation i n c l u d e both h e a r i n g l o s s c h a r a c t e r i s t i c s a n d n o n - h e a r i n g related v a r i a b l e s . S c h o w a n d N e r b o n n e ( 2 0 0 2 ) d e f i n e the c h a r a c t e r i s t i c s of h e a r i n g l o s s a s the d e g r e e a n d c o n f i g u r a t i o n of i m p a i r m e n t , t i m e of o n s e t , type of l o s s , a n d auditory s p e e c h r e c o g n i t i o n ability. T y e - M u r r a y ( 1 9 9 8 ) identifies n o n - a u d i t o r y v a r i a b l e s s u c h a s s t a g e of life, s o c i o e c o n o m i c s t a t u s , r a c e a n d ethnicity, g e n d e r , life f a c t o r s , a n d psychological adjustment.  K r i c o s ( 2 0 0 0 ) identifies a d d i t i o n a l influential f a c t o r s that  might affect rehabilitation s u c h a s p e r s o n a l i t y , s e l f - e f f i c a c y , s o c i a l s u p p o r t , h e a l t h status, a n d motivation.  F i n a l l y , K a r a s e k a n d T h e o r e l l ( 1 9 9 0 ) report that w o r k c o n d i t i o n s ,  s u c h a s j o b d e m a n d s a n d c o n t r o l , a s w e l l a s t r e n d s in the w o r k p l a c e , s u c h a s d o w n s i z i n g a n d u n e m p l o y m e n t , a r e r e l a t e d to h e a l t h in g e n e r a l . T h e g o a l s of a n a u r a l rehabilitation p r o g r a m , a s d e f i n e d by M o n t g o m e r y a n d H o u s t o n ( 2 0 0 0 ) a r e p r e s e n t e d in T a b l e 2 . 1 , with the a c c o m p a n y i n g time f r a m e for a c t i o n b y the client. T h i s e x a m p l e s h o w s the b r o a d v a r i a t i o n of g o a l s a r e r e l a t e d to e m o t i o n , attitudes, k n o w l e d g e , p e r c e p t i o n , a n d b e h a v i o r . T h e time c o u r s e is a l s o v a r i e d ; s o m e g o a l s o c c u r d u r i n g the p r o g r a m , w h i l e o t h e r s c o n t i n u e u p o n c o m p l e t i o n of the p r o g r a m .  10 Table 2.1. Goal activities of aural rehabilitation  (from Montgomery and Houston, 2000)  G o a l Activities R e d u c i n g n e g a t i v e e m o t i o n a l r e a c t i o n s related to c o m m u n i c a t i o n difficulties  T i m e F r a m e for A c t i o n by Client Long-term  M a k i n g c o g n i t i v e p r o c e s s e s a n d attitudes t o w a r d s h e a r i n g i m p a i r m e n t m o r e realistic I n c r e a s i n g c o n t e x t u a l k n o w l e d g e of c o m m u n i c a t i o n situations M a x i m i z i n g a u d i t o r y input t h r o u g h h e a r i n g a i d s a n d a s s i s t i v e listening d e v i c e s  Long-term  Using assertive behavior and applying educational knowledge Integrating auditory a n d v i s u a l input Minimizing communication breakdown through p r e v e n t a t i v e a c t i o n o r repair s t r a t e g i e s  B e f o r e a n d d u r i n g difficult situation D u r i n g situation A f t e r s o m e t h i n g is m i s s e d o r misunderstood  B e f o r e a n d d u r i n g rehabilitation B e f o r e a n d d u r i n g rehabilitation  A M o d e l of A u r a l R e h a b i l i t a t i o n S c h o w a n d N e r b o n n e ( 2 0 0 2 ) p r e s e n t a c o m p r e h e n s i v e m o d e l for a u r a l rehabilitation. T h i s a u r a l rehabilitation m o d e l , p r e s e n t e d in F i g u r e 2 . 1 , is b a s e d o n G o l d s t e i n a n d S t e p h e n s ( 1 9 8 1 ) , S t e p h e n s ( 1 9 9 6 a ) , a n d t h e current t e r m s u s e d b y t h e W H O ( 2 0 0 1 ) . T h e m o d e l c o n s i s t s of t w o m a j o r c o m p o n e n t s : a s s e s s m e n t a n d m a n a g e m e n t . T h e a s s e s s m e n t p r o c e d u r e s f o c u s o n c o m m u n i c a t i o n s t a t u s , o v e r a l l participation v a r i a b l e s , r e l a t e d p e r s o n a l f a c t o r s , a n d e n v i r o n m e n t a l f a c t o r s ( a b b r e v i a t e d C O R E ) . T h e four a s p e c t s of m a n a g e m e n t , a s d e f i n e d b y this m o d e l , a r e : c o u n s e l i n g a n d p s y c h o s o c i a l a s p e c t s , audibility o r a m p l i f i c a t i o n , r e m e d i a t i o n of c o m m u n i c a t i o n activity, a n d e n v i r o n m e n t a l c o o r d i n a t i o n o r participation i m p r o v e m e n t ( a b b r e v i a t e d C A R E ) . S e e S c h o w a n d N e r b o n n e ( 2 0 0 2 ) for a d e t a i l e d e x p l a n a t i o n of this m o d e l , a n d s e e P i c h o r a F u l l e r a n d S c h o w ( 2 0 0 2 ) for its a p p l i c a t i o n to a d u l t s w h o a r e h a r d - o f - h e a r i n g .  11  Figure 2.1. Model for audiologic rehabilitation.  (from Schow & Nerbonne, 2002, p.21)  12  A paradigm shift has changed the starting point for rehabilitation programming; now the client begins by telling the audiologist where the most troublesome problems exist in everyday life. The relationship between the client and clinician has developed into a partnership with shared responsibilities rather than one side holding the power and making all the decisions. This process can also become a multidisciplinary experience. Because of the expanding scope of rehabilitation practice, the audiologist is no longer expected to be the ultimate expert in every area. The client may also be recognized as an expert, and referrals can be made to other professionals such as acoustic engineers, architects, marriage counselors, psychiatrists, or teachers of the deaf and hard-ofhearing. Rehabilitative audiology does not only take place in the clinic; the significance of a client's environment has driven audiologists to work more in that environment. Group rehabilitation classes often occur in the community. Audiologists travel to places where their clients are having the most difficulty, whether that be the workplace, classroom, place of worship, or a friend's house during a bridge game. While none of these changes has come easily, the apparent relinquishing of power by the clinician or professional is viewed by many as progress toward an improved rehabilitation process, and with the client sharing the accountability for its success (Nussbaum, Pecchioni, & Crowell, 2001). In essence, the clinician is empowering the client with knowledge. This trend in audiological health care is parallel to others in the health care system (Bury, 2001). Aural rehabilitation has exhibited growth in many areas in the past 30 years. The effect of this growth has influenced many program components; for example, the topics covered in a program have developed to include assertiveness training, counseling, and controlling the environment. The paradigm shift has brought the focus of rehabilitation to emphasize functionality and generalizability. In some respects, we have returned to Carhart's early (1946) notion of audiology. The use of qualitative methods has shown us that important information can be obtained outside the sound booth, outside the clinic, and through questions that are neither standardized nor measured with numbers. A growing connection between audiological researchers and clinicians in the community has provided a strengthened and functionally-oriented foundation from which to collaborate and continue growing.  13 T h e p o w e r shift f r o m c l i n i c i a n to client a n d the m u l t i d i s c i p l i n a r y p r o s p e c t s a l s o s u p p o r t the s u b s t a n t i a l o n g o i n g d e v e l o p m e n t s of the field ( N u s s b a u m et a l . , 2 0 0 1 ) . Relevant Theoretical Models and Frameworks T h e Institute of M e d i c i n e ( 2 0 0 1 , p.183) r e c o g n i z e s that "effective p r o g r a m s to c h a n g e individual health b e h a v i o r r e q u i r e a multifaceted a p p r o a c h to h e l p i n g p e o p l e a d o p t , c h a n g e , a n d m a i n t a i n b e h a v i o r . " T h e r e m a i n d e r of this s e c t i o n will i n t r o d u c e a variety of t h e o r e t i c a l m o d e l s a n d f r a m e w o r k s r e l e v a n t to the i s s u e of h e l p - s e e k i n g by a d u l t s with hearing loss. W H O Model T h e W o r l d H e a l t h O r g a n i z a t i o n ( W H O ) h a s a m a n d a t e to d e v e l o p a g l o b a l l a n g u a g e in the field of h e a l t h ( W H O , 1 9 9 8 ) . In 1 9 8 0 , the W H O d e v e l o p e d a d o c u m e n t , International  Classification  of Impairments,  Disabilities,  and Handicap  (ICIDH) ( W H O ,  1 9 8 0 ) , w h i c h s e r v e d to d e f i n e the ' c o n s e q u e n c e s of d i s e a s e ' . T h i s d o c u m e n t p r o v i d e d a m e a n s to c a t e g o r i z e a n d d e s c r i b e t h e variety of e x p e r i e n c e s r e p o r t e d by i n d i v i d u a l s d e a l i n g with i m p a i r m e n t s , a n d it w a s d e v e l o p e d a s a c o m p l e m e n t to W H O ' s d o c u m e n t , I C D , International  Classification  of Disease  ( W H O , 1992). T h e ICD classifies health  c o n d i t i o n s but d o e s not a c k n o w l e d g e the e x p e r i e n c e s of t h e p e o p l e w h o live with the c o n d i t i o n s o n a d a y - t o - d a y b a s i s ; unlike the d i s e a s e m o d e l of the I C D , the I C I D H h a s a biopsychosocial approach. T h e I C I D H is c a s t in t e r m s of t h r e e inter-related c o m p o n e n t s / c o n c e p t s : the l o s s or a b n o r m a l i t y of a b i o l o g i c a l structure or f u n c t i o n ; disability: restriction or l a c k of ability to p e r f o r m a n activity; a n d handicap: e x p e r i e n c e d by a n individual with a n i m p a i r m e n t .  impairment:  t h e resulting  the s o c i a l d i s a d v a n t a g e  In h i n d s i g h t , w e a r e a w a r e of the  s h o r t c o m i n g s of t h i s trio o f c o n c e p t s a s d e f i n e d in 1 9 8 0 . F i g u r e 2 . 2 illustrates that t h e r e l a t i o n s h i p b e t w e e n t h e s e c o n c e p t s m a y b e interpreted a s r e p r e s e n t i n g c a u s a l i t y a n d indicating a c h a n g e o v e r t i m e , in a s i m p l e , u n i d i r e c t i o n a l , l i n e a r p r o g r e s s i o n . T h i s r e p r e s e n t a t i o n d o e s not p r o v i d e information o n the f a c t o r s m o d u l a t i n g r e l a t i o n s h i p s b e t w e e n the c o n c e p t s , nor d o e s it reflect t h e role of s o c i a l a n d p h y s i c a l e n v i r o n m e n t s in the difficulties e x p e r i e n c e d b y the p e r s o n with the i m p a i r m e n t . W e n o w a p p r e c i a t e that the c o n s e q u e n c e of i m p a i r m e n t is m u c h m o r e c o m p l i c a t e d .  14 Figure 2.2. The disablement phenomena as depicted in ICIDH in 1980. Disease or Disorder  lb Impairment  w  (WHO, 1980)  Disability  w  Handicap  T h e s e limitations w e r e a d d r e s s e d in a m o r e r e c e n t d o c u m e n t . S i g n i f i c a n t c h a n g e s h a v e b e e n i n t r o d u c e d t o t h e r e v i s e d d o c u m e n t , International Impairments,  Activities,  and Participation,  ICIHD-2  Classification  of  ( W H O , 1 9 9 8 ) , t h o u g h its m a i n  p u r p o s e r e m a i n s to p r o v i d e a d e s c r i p t i o n of a c t u a l h u m a n f u n c t i o n i n g w h i l e still c o m p l e m e n t i n g t h e m e d i c a l l y - o r i e n t e d I C D . W h i l e I C I D H p r o v i d e d d e f i n i t i o n s of i m p a i r m e n t , disability, a n d h a n d i c a p , I C I D H - 2 ( W H O , 1 9 9 8 ) , a n d m o s t r e c e n t l y t h e I C F , International  Classification  of Functioning,  Disability,  and Health  ( W H O , 2001), defines  t h r e e l e v e l s o f f u n c t i o n i n g in t h e c o n t e x t o f a h e a l t h c o n d i t i o n : i m p a i r m e n t , activity, a n d participation. T h e s e t e r m s p r o v i d e a f r a m e w o r k for u n d e r s t a n d i n g t h e d i m e n s i o n s of d i s a b l e m e n t (negative a s p e c t ) a n d f u n c t i o n i n g (positive a s p e c t ) at t h r e e different l e v e l s : b o d y , p e r s o n , a n d s o c i e t y . "Impairment  is a l o s s o r a b n o r m a l i t y o f b o d y structure o r of a  p h y s i o l o g i c a l o r p s y c h o l o g i c a l f u n c t i o n " ; " A n activity is t h e nature a n d extent of f u n c t i o n i n g at t h e level of the p e r s o n . A c t i v i t i e s m a y b e limited in n a t u r e , d u r a t i o n , a n d quality"; a n d "Participation  i s t h e n a t u r e a n d extent of a p e r s o n ' s i n v o l v e m e n t in relation  to i m p a i r m e n t , activities, h e a l t h c o n d i t i o n s , a n d c o n t e x t u a l f a c t o r s . P a r t i c i p a t i o n m a y b e restricted in n a t u r e , d u r a t i o n , a n d quality." ( W H O , 1 9 9 8 , p.8) T h e most obvious difference between the ICIDH a n d the I C F is the switch from disability to activity a n d f r o m h a n d i c a p to participation. F i g u r e 2 . 3 h e l p s to identify o t h e r c h a n g e s . " T h e interaction is c o m p l e x , b i - d i r e c t i o n a l , a n d d y n a m i c . T h e m o d e l d o e s not p o s i t a c a u s a l l i n k a g e b e t w e e n t h e t h r e e d i m e n s i o n s of d i s a b l e m e n t ; rather, at e a c h l e v e l , d i s a b l e m e n t o c c u r s within a n d by m e a n s of c o n t e x t u a l f a c t o r s . " ( W H O , 1 9 9 8 , p.7)  15 Figure 2.3. Model of the ICF.  (WHO, 2001) Health Condition (disorder or d i s e a s e )  x Body Function & Structure (impairment)  Activity (limitation)  Participation (restriction)  1  T 1 Environmental Factors  -  i  Personal Factors  I C F w a s d e v e l o p e d o n the f o u n d a t i o n of a b i o - p s y c h o - s o c i a l m o d e l , w h i c h e m p h a s i z e s universality; it is a p p l i c a b l e to all p e o p l e , i r r e s p e c t i v e of h e a l t h c o n d i t i o n . W h i l e a m e d i c a l m o d e l v i e w s d i s a b l e m e n t a s a p e r s o n a l p r o b l e m that r e q u i r e s p r o f e s s i o n a l intervention, the s o c i a l m o d e l v i e w s d i s a b l e m e n t f r o m the v i e w p o i n t of integration of p e r s o n s with disability into s o c i e t y . A s a result of the i n c l u s i o n of t h e s o c i a l m o d e l , e n v i r o n m e n t a l a n d p e r s o n a l c o n t e x t u a l f a c t o r s h a v e b e e n i n c l u d e d in the revised version. T h e environmental factors include social and physical elements s u c h a s s o c i a l attitudes, architectural d e s i g n s , l e g a l a n d s o c i a l s t r u c t u r e s , c l i m a t e , a n d terrain. T h e p e r s o n a l f a c t o r s i n c l u d e s u c h t h i n g s a s g e n d e r , a g e , other health conditions, coping styles, social b a c k g r o u n d , education, profession, past a n d current e x p e r i e n c e , o v e r a l l b e h a v i o r pattern, a n d c h a r a c t e r s t y l e . T h e s e f a c t o r s c a n b e u s e d to identify e n v i r o n m e n t a l barriers a n d facilitators that affect participation l e v e l s ( W H O , 1 9 9 8 ) . W h i l e t h e s e f a c t o r s m a y b e a p p l i e d to h e a r i n g l o s s , t h e y a r e a p p l i c a b l e to all health conditions. O t h e r c h a n g e s in the n e w v e r s i o n of the I C F a r e l e s s e v i d e n t .  I m p a i r m e n t s of  structure a n d i m p a i r m e n t s of function a r e n o w c l a s s i f i e d s e p a r a t e l y . H o w e v e r , d i s a b l e m e n t is not differentiated by etiology; there s h o u l d b e n o d i f f e r e n c e , at the activity or the participation l e v e l s , b e t w e e n p h y s i c a l a n d m e n t a l health c o n d i t i o n s . A l l definitions a r e n o w o p e r a t i o n a l l y d e f i n e d a n d j u d g m e n t s a r e b a s e d o n w h a t a p e r s o n d o e s a s o p p o s e d to w h a t t h e y m a y b e a b l e to d o ; the b a s i c attributes, b o u n d a r i e s , a n d m e a s u r e m e n t c h a r a c t e r i s t i c s of the c o n c e p t s a r e p r o v i d e d . A neutral l a n g u a g e h a s  16 b e e n u s e d w h i l e retaining the ability to e x p r e s s both positive a n d n e g a t i v e a s p e c t s of e a c h d i m e n s i o n (e.g., c o m p l e t e participation v e r s u s participation restrictions).  The  distinction b e t w e e n disability a n d h a n d i c a p f r o m the p r e v i o u s m o d e l is m o r e explicit t h a n t h e d i f f e r e n c e b e t w e e n activity a n d participation; the distinction of c o n s e q u e n c e of a h e a l t h c o n d i t i o n at the p e r s o n v e r s u s the s o c i e t y level is b l u r r e d . F i n a l l y , t h e I C F w a s d e v e l o p e d to s u p p o r t t h e c o n c e p t of universality. T h e c l a s s i f i c a t i o n s a r e a p p l i c a b l e to all p e o p l e ; it is not a m e a n s to s p e c i f i c a l l y l a b e l p e o p l e with d i s a b l e m e n t s ( W H O , 2 0 0 1 ) . T h e e v o l u t i o n of t h e p r o p o s e d c o n s e q u e n c e s of a h e a l t h c o n d i t i o n , f r o m the I C I D H to the I C F , h a s p r o v i d e d fuel for the revolution in a u r a l rehabilitation. T h e I C F d e m o n s t r a t e s the significant i m p a c t of, a n d the n e e d to a d d r e s s , the e n v i r o n m e n t a l a n d p e r s o n a l f a c t o r s of the c o n s e q u e n c e s of a h e a l t h c o n d i t i o n . T h i s i m p a c t , a l o n g with t h e notion of participation a n d participation restrictions, directly relate to the g o a l s of a u r a l rehabilitation a n d t h e d e c i s i o n to s e e k h e l p . E m p i r i c a l r e s e a r c h h a s s h o w n that e n v i r o n m e n t a l a n d p e r s o n a l f a c t o r s affect the d e g r e e to w h i c h h e a r i n g i m p a i r m e n t i m p a c t s a n i n d i v i d u a l . T h e a c k n o w l e d g e m e n t of limitations a n d restrictions is r e l e v a n t , s i n c e t h e s e a r e the f a c t o r s that r e p r e s e n t the true m e a s u r e of t h e i m p a c t of h e a r i n g l o s s . T h e shift f r o m i m p a i r m e n t to a m o r e e c o l o g i c a l a p p r o a c h to h e a l t h c a r e h a s p r o v i d e d i m p e t u s for t h e c h a n g e f r o m the f o c u s o n t r e a t m e n t a n d c u r e to that of m a n a g e m e n t a n d c a r e (Bury, 2 0 0 1 ) . D e t e r m i n a n t s of H e a l t h T h e a c k n o w l e d g e m e n t of the v a r i e d d e t e r m i n a n t s of h e a l t h by the W H O m o d e l s w a s p r e c e d e d , for e x a m p l e , by t h e L a l o n d e report in 1 9 7 4 . T h i s report s u g g e s t s t h e i m p o r t a n c e of lifestyle a n d i n d i v i d u a l b e h a v i o r a s n e c e s s a r y t a r g e t s of h e a l t h interventions.  E v a n s a n d S t o d d a r d ( 1 9 9 0 ) d e v e l o p e d a m o d e l of the d e t e r m i n a n t s of  h e a l t h ( s e e F i g u r e 2.4). T h i s m o d e l d e m o n s t r a t e d that b e h a v i o r is not m e r e l y a p e r s o n a l c h o i c e but is s h a p e d b y multiple f o r c e s . H e a l t h a n d b e h a v i o r a r e i n f l u e n c e d by b i o l o g i c a l , p s y c h o l o g i c a l , a n d s o c i a l f a c t o r s , a n d the s u c c e s s of h e a l t h y interventions d e p e n d s o n the integration of t h e s e f a c t o r s (Institute of M e d i c i n e , 2 0 0 1 ) . T h i s m o d e l is r e l e v a n t to the current r e s e a r c h ; t h e d e t e r m i n a n t s of health a n d the i n f l u e n c e of t h e s e f a c t o r s might p r o v i d e insight into t h e f a c t o r s that p r e v e n t or p r o m o t e h e l p - s e e k i n g .  17 Figure 2.4. A model of the determinants of health,  Individual Response - Behaviour - Biology  Social Environment  Health and Function  (from Institute of Medicine, 2001, p.25)  Physical Environment  Genetic Environment  Disease  Health Care  WeilBeing  Prosperity  S u c h i d e a s a r e c o n s i s t e n t with a n e c o l o g i c a l a p p r o a c h to h e a l t h a n d b e h a v i o r ; t h e notion of e c o l o g i c a l a u d i o l o g y will b e revisited later in this c h a p t e r . T h e i m p o r t a n c e of the c h a r a c t e r i s t i c s of t h e individual a n d h i s o r h e r e n v i r o n m e n t is a n t i c i p a t e d in t h e theoretical m o d e l s presented here. Health Belief M o d e l T h e r e a r e v a r i o u s m o d e l s that a t t e m p t to e x p l a i n h e a l t h b e l i e f s . O n e of t h e e a r l i e s t t h e o r e t i c a l m o d e l s d e v e l o p e d for u n d e r s t a n d i n g h e a l t h b e h a v i o r s w a s t h e h e a l t h belief m o d e l ( H B M ) , which f o c u s e s o n p e o p l e ' s beliefs about health threats a n d the costs a n d b e n e f i t s of h e a l t h b e h a v i o r ( B e c k e r , 1 9 7 4 ; B e c k e r & M a i m a n , 1 9 7 5 ) . F i g u r e 2 . 5 p r e s e n t s a n interpretation of t h e H B M . T h i s m o d e l w a s d e v e l o p e d in t h e 1 9 5 0 s in a n effort to e x p l a i n the l a c k of c e r t a i n h e a l t h - r e l a t e d b e h a v i o r s to p r e v e n t o r d e t e c t d i s e a s e . P e r c e i v e d s u s c e p t i b i l i t y a n d s e v e r i t y p r o v i d e m o t i v a t i o n for a d o p t i n g a h e a l t h - p r o m o t i n g behavior, while the action taken d e p e n d s o n perceived benefits a n d barriers. T h e n e g a t i v e a s p e c t s a s s o c i a t e d with that b e h a v i o r a r e w e i g h e d a g a i n s t the e f f e c t i v e n e s s of t h e b e h a v i o r (Institute of M e d i c i n e , 2 0 0 1 ) . T h e s i g n i f i c a n c e of t h e H B M to t h e current s t u d y c a n b e d e m o n s t r a t e d b y t h e potential a p p l i c a t i o n s of t h e m o d e l , a s s u g g e s t e d b y P o r t e r a n d c o l l e a g u e s ( 1 9 9 9 , p.54); t h e y identify k e y a p p l i c a t i o n s of t h e H B M a s "identifying h e a l t h p r o m o t i o n t a r g e t s at individual a n d p o p u l a t i o n l e v e l s , identifying t h o s e l e a s t likely to c o m p l y with m e d i c a l t r e a t m e n t o r a d v i c e , a n d u n d e r s t a n d i n g w h y s o m e  18 p e o p l e put their h e a l t h at risk". T h e c o m p o n e n t s of t h e H B M a n d the e s s e n c e of a c t i o n a d d r e s s e d b y the m o d e l a r e directly related to the p r o c e s s of h e l p - s e e k i n g . Figure 2.5. Health Belief Model,  (from Porter et al., 1999)  Perceived susceptibility Demographic Variables Class, gender, a g e , etc.  Perceived severity  Health motivation Psychological characteristics Personality, peer group pressure, etc.  w  Action  Perceived benefits C u e s to action  ->  Perceived barriers  O t h e r t h e o r i e s a r e a l s o potentially r e l e v a n t to t h e current s t u d y , t h r o u g h their relation to b e h a v i o r c h a n g e , c o p i n g , a n d a d a p t a t i o n , a n d t h e s e t h e o r i e s a r e r e v i e w e d b e l o w . Social Learning Theory W h i l e l e a r n i n g t h e o r y p r o p o s e s that r e i n f o r c e m e n t is the s o l e d e t e r m i n a n t of b e h a v i o r , c o g n i t i v e s o c i a l l e a r n i n g t h e o r y ( B a n d u r a , 1 9 8 6 ) a c k n o w l e d g e s that b e h a v i o r also c h a n g e s by observing others. S o c i a l learning theory p l a c e s considerable i m p o r t a n c e o n the e n v i r o n m e n t , a n d o t h e r p e o p l e c o n s t i t u t e t h e m o s t important a s p e c t of the e n v i r o n m e n t . A n o t h e r important c o m p o n e n t of this t h e o r y is s e l f - e f f i c a c y , or the belief that y o u a r e c a p a b l e of m a k i n g n e c e s s a r y b e h a v i o r a l c h a n g e s to c r e a t e a d e s i r e d o u t c o m e (Institute of M e d i c i n e , 2 0 0 1 ) . B a n d u r a e x p l a i n s s e l f - e f f i c a c y a s : " . . . n o t s i m p l y inert e s t i m a t e s of future a c t i o n . P e o p l e ' s b e l i e f s a b o u t their o p e r a t i v e c a p a b i l i t i e s f u n c t i o n a s o n e s e t of p r o x i m a l d e t e r m i n a n t s of h o w t h e y b e h a v e , their t h o u g h t p a t t e r n s , a n d the e m o t i o n a l r e a c t i o n s t h e y e x p e r i e n c e in t a x i n g s i t u a t i o n s . S e l f - b e l i e f s t h u s contribute to the quality of p s y c h o s o c i a l f u n c t i o n i n g in d i v e r s e w a y s . In their daily l i v e s p e o p l e h a v e to m a k e d e c i s i o n s all t h e t i m e a b o u t w h a t c o u r s e s of a c t i o n to p u r s u e a n d h o w l o n g to c o n t i n u e w h a t t h e y h a v e u n d e r t a k e n . D e c i s i o n s  19 involving c h o i c e of activities a n d c e r t a i n s o c i a l m i l i e u s a r e partly d e t e r m i n e d by j u d g m e n t s of p e r s o n a l e f f i c a c y . P e o p l e t e n d to a v o i d t a s k s a n d situations t h e y b e l i e v e e x c e e d their c a p a b i l i t i e s , but they u n d e r t a k e a n d p e r f o r m a s s u r e d l y activities t h e y j u d g e t h e m s e l v e s to b e c a p a b l e of h a n d l i n g . A n y factor that i n f l u e n c e s c h o i c e b e h a v i o r c a n h a v e p r o f o u n d effects o n the c o u r s e of p e r s o n a l d e v e l o p m e n t . A d v a n t a g e o u s selfp e r c e p t s of e f f i c a c y that f o s t e r a c t i v e e n g a g e m e n t in activities contribute to g r o w t h of c o m p e t e n c i e s . In contrast, p e r c e i v e d s e l f - i n e f f i c a c i e s that l e a d p e o p l e to s h u n e n r i c h i n g e n v i r o n m e n t s a n d activities retard d e v e l o p m e n t of potentialities a n d s h i e l d n e g a t i v e s e l f - p e r c e p t s f r o m c o r r e c t i v e c h a n g e . R e a s o n a b l y a c c u r a t e a p p r a i s a l of o n e ' s o w n c a p a b i l i t i e s is, t h e r e f o r e , of c o n s i d e r a b l e v a l u e in s u c c e s s f u l f u n c t i o n i n g . " ( B a n d u r a , 1 9 8 6 , p.393) Social Comparison Theory A l t h o u g h F e s t i n g e r (1954) first u s e d the t e r m ' s o c i a l c o m p a r i s o n ' , r e s e a r c h r e g a r d i n g c o m p a r i s o n p r o c e s s e s h a s a history s p a n n i n g m a n y d e c a d e s ( B u u n k , G i b b o n s , & R e i s B e r g a n , 1 9 9 7 ; H y m a n , 1 9 4 2 ; Sherif, 1 9 3 6 ) . L e v e n t h a l , H u d s o n , a n d R o b i t a i l l e ( 1 9 9 7 , p.411) o b s e r v e that: " s o c i a l c o m p a r i s o n t h e o r y w a s originally b a s e d o n a fairly s i m p l e a s s u m p t i o n : In t i m e s of uncertainty, w h e n other m e a n s for o b j e c t i v e e v a l u a t i o n a r e l a c k i n g , i n d i v i d u a l s c o m p a r e t h e m s e l v e s to s i m i l a r o t h e r s to e v a l u a t e their o w n o p i n i o n s a n d abilities".  D o w n w a r d c o m p a r i s o n s i n v o l v e c o m p a r i s o n s with o t h e r s in s i m i l a r c i r c u m s t a n c e s w h o a r e d o i n g w o r s e o n the c o m p a r e d d i m e n s i o n , with the p u r p o s e of f e e l i n g better a b o u t o n e s e l f . U p w a r d c o m p a r i s o n s a r e c o m p a r i s o n s with o t h e r s t h o u g h t to b e d o i n g better. T h e r e is s o m e d e b a t e in the literature r e g a r d i n g the p u r p o s e of, a n d the e x p e c t a t i o n s a s s o c i a t e d with, t h e s e c o m p a r i s o n s . T a y l o r a n d L o b e l (1989) d i s c u s s the direction of s o c i a l c o m p a r i s o n u n d e r s t r e s s . T h e s e a u t h o r s b e l i e v e that a c o m p a r i s o n with o t h e r s w h o a r e c o p i n g w e l l with their p r o b l e m s ( u p w a r d c o m p a r i s o n ) m a y s e r v e to i m p r o v e the current situation by p r o v i d i n g i d e a s for positive c o p i n g , p r o v i d i n g h o p e , motivation, a n d inspiration, a n d e n h a n c i n g the p e r s o n ' s s e n s e of s e l f - e f f i c a c y ; this style implies problem-focused coping. Alternatively, individuals m a y also use d o w n w a r d s o c i a l c o m p a r i s o n s a s a m e a n s of e m o t i o n - f o c u s e d c o p i n g , a n d a s a n effort to a l l e v i a t e negative emotions.  B y c o m p a r i n g the s e l f to o t h e r s s e e n a s w o r s e off h e l p s the  individual feel better a b o u t him or herself. C o p i n g s t y l e s will b e d i s c u s s e d later in this chapter.  20 L e v e n t h a l et a l . ( 1 9 9 7 ) p r o p o s e that s o c i a l c o m p a r i s o n is a p r o c e s s rather t h a n a trait; the role of s o c i a l c o m p a r i s o n is d e t e r m i n e d by the i n d i v i d u a l ' s motivation in e a c h s p e c i f i c s i t u a t i o n . T h e r e - e m e r g e n c e of the e c o l o g i c a l t h e m e is p r e s e n t h e r e in that s o c i a l c o m p a r i s o n s a r e c o m p a t i b l e with the e c o l o g i c a l p e r s p e c t i v e . T h e c o n s t r u c t of s o c i a l c o m p a r i s o n is r e l e v a n t to the current s t u d y b e c a u s e p a r t i c i p a n t s w e r e s t u d i e d with r e s p e c t to i n v o l v e m e n t in a g r o u p h e a r i n g rehabilitation p r o g r a m . B u u n k , G i b b o n s , a n d R e i s - B e r g a n ( 1 9 9 7 ) report that s o c i a l c o m p a r i s o n h e l p s to e x p l a i n t h e popularity of s u p p o r t g r o u p s ; i n d i v i d u a l s u n d e r s t r e s s often prefer c o n t a c t with o t h e r s with s i m i l a r i s s u e s a n d e x p e r i e n c e s . T h e s e i n d i v i d u a l s a p p e a r to b e effective at p r o v i d i n g s o c i a l s u p p o r t , a n d participation in t h e s e g r o u p s " r e d u c e s f e e l i n g s of u n i q u e n e s s or d e v i a n c e " ( B u u n k et a l . , 1 9 9 7 , p.7). In addition to the g r o u p e x p e r i e n c e , s o c i a l c o m p a r i s o n s a l s o p l a y a role in the d e c i s i o n to s e e k h e l p for m e d i c a l p r o b l e m s f r o m r e l a t i v e s , f r i e n d s , a n d a c q u a i n t a n c e s ( S u i s , M a r t i n , & L e v e n t h a l , 1 9 9 7 ) . P e o p l e n e e d a c c u r a t e a s s e s s m e n t s of their abilities a n d they find uncertainty disconcerting. Before s e e k i n g m e d i c a l help f r o m a p r o f e s s i o n a l , a n individual might s e e k information f r o m their lay network to e x p l o r e if t h e r e is a p r o b l e m , if the p r o b l e m is s e r i o u s , a n d if p r o f e s s i o n a l intervention is r e q u i r e d . Transtheoretical Model T h e t r a n s t h e o r e t i c a l m o d e l , or s t a g e s of c h a n g e m o d e l , w a s p r o p o s e d b y P r o c h a s k a a n d D i C l e m e n t e ( 1 9 8 6 ) . T h e m o d e l i s b a s e d o n t h r e e d i m e n s i o n s of c h a n g e : l e v e l of c h a n g e , s t a g e of c h a n g e , a n d p r o c e s s of c h a n g e . T h i s m o d e l e n t a i l s a s e r i e s of s t e p s that p e o p l e t a k e t h r o u g h c h a n g e . T h e e a r l i e s t s t e p , precontemplation, p e o p l e m a y b e u n i n t e r e s t e d or unwilling to c h a n g e . Contemplation,  r e c o g n i z e s that a step where  p e o p l e a r e c o n s i d e r i n g a c h a n g e , is f o l l o w e d b y preparation,  the d e c i s i o n to t a k e a c t i o n ,  a n d t h e n the s t e p of action.  is the final s t e p in the  T h e s t a g e l a b e l e d maintenance  p r o c e s s . E r d m a n ( 2 0 0 0 ) d e s c r i b e s that: " r e a d i n e s s for c h a n g e c o n s i s t s of a d e c i s i o n - m a k i n g p r o c e s s that is d r i v e n by shifts in b a l a n c e b e t w e e n the i n d i v i d u a l ' s p e r c e i v e d p r o s a n d c o n s of changing behavior."  T h i s m o d e l p r o v i d e s a g u i d e for the a p p r o p r i a t e n e s s of s t r a t e g i e s b a s e d o n a n i n d i v i d u a l ' s c u r r e n t p l a c e m e n t in the m o d e l . F o r e x a m p l e , c o g n i t i v e i n t e r v e n t i o n s t a r g e t e d to e n c o u r a g e c h a n g e s in attitude a r e m o r e a p p r o p r i a t e d u r i n g the  21 precontemplation a n d contemplation stages ( P r o c h a s k a , Velicer, DiClemente, & F a v a , 1 9 8 8 ) . T h i s p r o c e s s of c h a n g e a n d t h e s t a g e s identified in this m o d e l might b e relevant in d i s t i n g u i s h i n g b e t w e e n t h o s e w h o c h o o s e to s e e k h e l p t h r o u g h g r o u p h e a r i n g rehabilitation p r o g r a m s a n d t h o s e w h o d o not. Coping a n d Adjustment T h e c o n c e p t of a d a p t a t i o n w a s t h e c o r n e r s t o n e of D a r w i n ' s theory o f e v o l u t i o n a n d the s u r v i v a l of a s p e c i e s ( 1 8 5 9 ) . T h i s b i o l o g i c a l c o n c e p t h a s b e e n b o r r o w e d b y p s y c h o l o g y a n d " r e n a m e d adjustment to e m p h a s i z e t h e i n d i v i d u a l ' s s t r u g g l e to g e t a l o n g o r s u r v i v e in h i s o r h e r s o c i a l a n d p h y s i c a l e n v i r o n m e n t s " ( L a z a r u s , 1 9 7 6 , p.3). T h e r e a r e a large n u m b e r of m o d e l s d e s i g n e d to d e s c r i b e t h e p r o c e s s of c o p i n g . L a z a r u s a n d F o l k m a n (1984) d e f i n e t w o c a t e g o r i e s of c o p i n g a s p r o b l e m - f o c u s e d a n d emotion-focused.  M o o s (1986) a d d s a third c a t e g o r y of c o p i n g : a p p r a i s a l - f o c u s e d . T h e  s t r a t e g i e s attributed to e a c h of t h e s e c a t e g o r i e s a r e p r e s e n t e d in T a b l e 2 . 2 . P r o b l e m f o c u s e d c o p i n g r e s p o n s e s a r e d i r e c t e d at t h e c a u s e of t h e s t r e s s , w h i l e e m o t i o n f o c u s e d c o p i n g a r e d i r e c t e d at regulating s t r e s s . G a t h e r i n g information a n d s o l v i n g p r o b l e m s a r e p r o b l e m - f o c u s e d , but a v o i d i n g p r o b l e m s is e m o t i o n - f o c u s e d . A d a m s a n d B r o m l e y ( 1 9 9 8 , p.104) interpret M o o s ' a d a p t i v e t a s k s for a p p r o p r i a t e c o p i n g a s : " e s t a b l i s h m e a n i n g a n d s i g n i f i c a n c e of t h e s i t u a t i o n , confront reality, s u s t a i n healthy r e l a t i o n s h i p s , m a i n t a i n a r e a s o n a b l e e m o t i o n a l b a l a n c e , and preserve a satisfactory self-image"  Table 2.2. Categories of coping and their related strategies Categories of Coping  (from Adams & Bromley, 1998, p. 103)  Related Strategies  Problem-focused  A c t i v e l y c o n f r o n t i n g p r o b l e m s a n d d e a l i n g with t h e consequences e . g . , a d v i c e , information, f e e d b a c k o n p r o g r e s s  Emotion-focused  D e v e l o p i n g skills for t h e m a n a g e m e n t of f e e l i n g s e.g., denial a v o i d a n c e , relaxation therapy, humor  Appraisal-focused  D e v e l o p i n g skills to m o d i f y a n d c o m p r e h e n d t h e threat of a situation  Individuals c h o o s e to c o p e with h e a r i n g l o s s in a variety of w a y s , a n d c o p i n g c h o i c e s may b e situation-dependent.  P r o b l e m - a n d e m o t i o n - f o c u s e d c a t e g o r i e s of c o p i n g  b e h a v i o r s h a v e b e e n d o c u m e n t e d a s a m e a n s of d e a l i n g with h e a r i n g l o s s ( H a l l b e r g & C a r l s s o n , 1 9 9 1 ) , a n d c h o i c e of c o p i n g style m a y relate to t h e r e a c t i o n to h e a r i n g l o s s a n d t h e d e c i s i o n to s e e k h e l p .  22  T h i s s e c t i o n r e v i e w e d e x i s t i n g t h e o r e t i c a l m o d e l s that a r e r e l e v a n t to the current s t u d y . T h e I C F m o d e l ( W H O , 2 0 0 1 ) , the d e t e r m i n a n t s of h e a l t h m o d e l ( E v a n s & S t o d d a r d , 1 9 9 0 ) , a n d the health belief m o d e l ( B e c k e r , 1 9 7 4 ; B e c k e r & M a i m a n , 1 9 7 5 ) p r o v i d e a n u n d e r s t a n d i n g of h e a l t h - r e l a t e d b e h a v i o r n e c e s s a r y for the further u n d e r s t a n d i n g of h e l p - s e e k i n g b e h a v i o r . T h e s o c i a l l e a r n i n g t h e o r y ( B a n d u r a , 1 9 8 6 ) , t h e s o c i a l c o m p a r i s o n t h e o r y ( F e s t i n g e r , 1 9 5 4 ) , a n d the H B M ( B e c k e r , 1 9 7 4 ; B e c k e r & M a i m a n , 1 9 7 5 ) p r o v i d e a n u n d e r s t a n d i n g of w h y i n d i v i d u a l s might i n v e s t in h e l p - s e e k i n g b e h a v i o r . F i n a l l y , t h e o r i e s relating to c o p i n g a n d a d j u s t m e n t by L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) a n d M o o s ( 1 9 8 6 ) s u g g e s t h o w i n d i v i d u a l s might c o p e with difficult s i t u a t i o n s . T h e following s e c t i o n i n t r o d u c e s r e l e v a n t t h e o r i e s r e l a t e d to t h e c o n c e p t of identity. T h e Identity P e r s p e c t i v e H e a r i n g l o s s h a s m a n y i m p l i c a t i o n s at the level of the p e r s o n . G o f f m a n ( 1 9 6 3 ) r e v i e w s the origins of stigma  f r o m e a r l y G r e e k a n d C h r i s t i a n t i m e s a s s i g n s to s h o w a  d i f f e r e n c e in m o r a l s t a t u s , s i g n s of holy g r a c e , o r m o r e r e c e n t l y , a s bodily s i g n s of a p h y s i c a l d i s o r d e r . T h e m o d e r n m e a n i n g of s t i g m a refers m o r e to the d i s g r a c e t h a n to t h e bodily e v i d e n c e of d i f f e r e n c e . G o f f m a n e x p l a i n s that w e h a v e a n t i c i p a t i o n s of p e o p l e that h a v e b e c o m e n o r m a t i v e e x p e c t a t i o n s , a n d w e g i v e p e o p l e a normative identity.  Individual c h a r a c t e r traits d e t e r m i n e a p e r s o n ' s actual social  social  identity.  When a  d i s c r e p a n c y b e t w e e n t h e s e t w o identities e x i s t s , t h e r e is " a s t i g m a . . . a failing, a s h o r t c o m i n g , a h a n d i c a p " ( G o f f m a n , 1 9 6 3 , p.3). H o w e v e r , a n important distinction is w h e t h e r t h e individual b e l i e v e s that o t h e r s s e e o r d o not s e e t h e d i f f e r e n c e - w h e t h e r h i s d i f f e r e n t n e s s is e v i d e n t to o t h e r s {discredited)  or not  (discreditable).  " T h i s d i s c r e p a n c y , w h e n k n o w n a b o u t or a p p a r e n t , s p o i l s his s o c i a l identity; it h a s t h e effect of cutting him off f r o m s o c i e t y a n d f r o m h i m s e l f s o that h e s t a n d s a d i s c r e d i t e d p e r s o n f a c i n g a n u n a c c e p t i n g w o r l d . " ( G o f f m a n , 1 9 6 3 , p. 19) G o f f m a n ' s interpretation of s t i g m a h a s b e e n s t u d i e d in relation to h e a r i n g l o s s .  Hetu  ( 1 9 9 6 ) e x a m i n e s the s t i g m a a t t a c h e d to h e a r i n g l o s s a n d reports that the e x p e r i e n c e of h e a r i n g l o s s is a threat to a p e r s o n ' s s o c i a l identity.  H e t u identifies t h e i m p a c t of t h e  s t i g m a a t t a c h e d to h e a r i n g l o s s a n d a d d r e s s e s its s i g n i f i c a n c e for rehabilitation. S t i g m a e x a c e r b a t e s h a n d i c a p a n d is a m a j o r o b s t a c l e to rehabilitation i n s o f a r a s a c c e p t i n g h e a r i n g l o s s is a p r e r e q u i s i t e to rehabilitation. A p o s s i b l e g o a l of rehabilitation is n o r m a l i z a t i o n , or restoring the s o c i a l identity of t h o s e with h e a r i n g l o s s . S o c i a l , cultural,  23 a n d p s y c h o l o g i c a l f a c t o r s of n o r m a l i z a t i o n m u s t b e c o n s i d e r e d for e a c h i n d i v i d u a l , a s s o c i a l interactions a r e i d i o s y n c r a t i c . D a n e r m a r k ( 1 9 9 8 ) a r g u e s that f e a r of l o s i n g f a c e is c r u c i a l in interaction a n d that s h a m e is a n important e m o t i o n . D a n e r m a r k b e l i e v e s that e m o t i o n a l p r o b l e m s , w h i c h a r e p e r s o n a l but h a v e a significant s o c i a l d i m e n s i o n , a r e o n e of the m o s t s e r i o u s c o n s e q u e n c e s of h e a r i n g l o s s a n d s h o u l d r e c e i v e explicit attention in rehabilitation p r o g r a m s . T h e c o n c e p t s of s t i g m a a n d p e r s o n a l identity e n t e r into a d i s c u s s i o n of a hard-ofhearing  identity.  P e o p l e w h o a r e h a r d - o f - h e a r i n g a r e often c o m p a r e d with D e a f p e o p l e ,  w h o exhibit a v e r y s t r o n g s e n s e of identity.  D o e s a s i m i l a r identity e x i s t for t h o s e with  h e a r i n g l o s s ? L a s z l o ( 1 9 9 4 ) a d d r e s s e s this t o p i c t h r o u g h a d i s c u s s i o n of a w a r e n e s s o n t h e part of the h e a r i n g w o r l d a n d o n the part of t h o s e w h o a r e h a r d - o f - h e a r i n g . T h e s e l e v e l s of a w a r e n e s s h a v e a direct i m p a c t o n c o p i n g a n d s o c i a l integration, but t h e r e is g e n e r a l l y little visibility a n d g e n e r a l s o c i a l a w a r e n e s s or u n d e r s t a n d i n g of p e o p l e with h e a r i n g l o s s . L a s z l o q u e s t i o n s the h e a r i n g w o r l d ' s a w a r e n e s s with t w o q u e s t i o n s : H o w m a n y p e o p l e a r e a w a r e that p e o p l e w h o a r e h a r d - o f - h e a r i n g c a n b e f o u n d in all a g e g r o u p s , in all w a l k s of life, in v a r i e d o c c u p a t i o n s , p r o f e s s i o n s , arts, a n d s c i e n c e s ?  How  m a n y p e o p l e a r e a w a r e of the p s y c h o l o g i c a l a n d s o c i a l p r o b l e m s of b e i n g hard-ofh e a r i n g ? H e reports that: " A s a rule, h a r d - o f - h e a r i n g p e o p l e attempt to c o p e with t h e h e a r i n g w o r l d o n its o w n t e r m s . W o r k , e d u c a t i o n , f a m i l y life, a n d t h e w h o l e r a n g e of h u m a n interaction rely h e a v i l y o n t h e s p o k e n w o r d , a n d m o r e g e n e r a l l y o n the a c o u s t i c a l w o r l d . T h u s h a r d - o f - h e a r i n g p e o p l e m u s t m a k e a t r e m e n d o u s effort to a d a p t to e v e r c h a n g i n g a c o u s t i c a l , t e c h n i c a l , a n d c o m m u n i c a t i o n c i r c u m s t a n c e s ; they must also o v e r c o m e the barriers a n d o b s t a c l e s that result f r o m i n c o m p l e t e c o m p r e h e n s i o n of t h e s p o k e n w o r d a n d i n c o m p l e t e c o n t a c t with t h e a c o u s t i c a l w o r l d . " ( L a s z l o , 1 9 9 4 , p.249)  A w a r e n e s s o n t h e part of the p e o p l e with h e a r i n g l o s s is a l s o c r u c i a l . T h e p e r s o n with h e a r i n g l o s s m u s t r e a l i z e that t h e r e a r e o t h e r i n d i v i d u a l s w h o s h a r e t h e s a m e e x p e r i e n c e . L a s z l o a l s o o u t l i n e s four r e q u i r e m e n t s o n the part of the p e r s o n w h o is h a r d - o f - h e a r i n g in a s s u m i n g p e r s o n a l r e s p o n s i b i l i t y , w h i c h is n e c e s s a r y for a c c e p t a n c e of the l o s s a n d m a i n t e n a n c e of a fulfilling life: o b t a i n i n g k n o w l e d g e r e g a r d i n g h e a r i n g l o s s a n d m a i n t a i n i n g realistic rehabilitation g o a l s , participating a c t i v e l y in rehabilitation, t a k i n g r e s p o n s i b i l i t y for o n e ' s o w n h e a l t h , a n d b e c o m i n g familiar with t e c h n o l o g i c a l a i d s . R e g a r d i n g the e x i s t e n c e of a h a r d - o f - h e a r i n g identity, L a s z l o b e l i e v e s t h e d e g r e e of difficulty, a s w e l l a s p e r s o n a l s u c c e s s of c o p i n g with h e a r i n g l o s s , affect the f e e l i n g of  24 'community'.  W h i l e a d e f i n e d identity w o u l d h a v e s o m e practical b e n e f i t s , the l a c k of a  c o m m o n identity that e x i s t s for the g r o u p c o m p l i c a t e s efforts to c h a n g e the a w a r e n e s s , p e r c e p t i o n s , a n d c o n s e q u e n c e s of h e a r i n g l o s s o n the part of m e m b e r s of s o c i e t y in g e n e r a l . A n identity e x i s t s in the s e n s e that there is a g r o u p w h o s e difficulty with a n a c o u s t i c a l w o r d u n i t e s t h e m ; h o w e v e r , it is important to r e c o g n i z e that t h e s e i n d i v i d u a l s a r e not d e f i n e d by their h e a r i n g l o s s . B u r y ( 2 0 0 1 , p.269), t h r o u g h a d i s c u s s i o n r e g a r d i n g i l l n e s s n a r r a t i v e s , d e f i n e s t w o b r o a d c o n c e p t s of d i s e a s e a n d i l l n e s s , w h i c h a r e r e l e v a n t to this d i s c u s s i o n of identity: " O n the o n e h a n d t h e r e is a c a t e g o r i c a l v i e w of i l l n e s s b a s e d o n the s e p a r a t i o n of the n o r m a l a n d the p a t h o l o g i c a l , w h e r e o b j e c t i v e s i g n s a n d s y m p t o m s a r e differentiated f r o m k n o w n or putative n o r m a l s t a t e s , a n d w h e r e the o n s e t a n d c o u r s e of the d i s e a s e is relatively c l e a r - c u t . O n the other h a n d t h e r e is the s p e c t r a l v i e w in w h i c h the d i f f e r e n c e b e t w e e n d i s e a s e a n d i l l n e s s is a matter of d e g r e e a n d a function of s o c i a l p r o c e s s ; the o c c u r r e n c e of i l l n e s s , e s p e c i a l l y c h r o n i c i l l n e s s , is h e r e e s s e n t i a l l y e m e r g e n t in c h a r a c t e r , d e p e n d i n g strongly o n s o c i a l c i r c u m s t a n c e a n d societal reaction." B u r y a l s o d i s t i n g u i s h e s b e t w e e n two r e a c t i o n s of a n individual to i l l n e s s . A p e r s o n m a y try to " n o r m a l i z e " by retaining a p r e - i l l n e s s lifestyle a n d identity. A l t e r n a t i v e l y , a p e r s o n m a y i n c o r p o r a t e the i l l n e s s into a c h a n g e d lifestyle. " N o r m a l life is r e d e s i g n e d a s c o n t a i n i n g the i l l n e s s a n d b e i n g o p e n a b o u t it." (Bury, 2 0 0 1 , p.272) T h i s s e c t i o n h a s i n t r o d u c e d the c o n c e p t of identity, t h r o u g h the w o r k of G o f f m a n ( 1 9 6 3 ) , a n d related the c o n c e p t of s t i g m a to the e x p e r i e n c e s of i n d i v i d u a l s a n d g r o u p s w h o a r e h a r d - o f - h e a r i n g . T h e following s e c t i o n e x p a n d s o n this v i e w to o n e that i n c o r p o r a t e s the e n v i r o n m e n t for a m o r e e c o l o g i c a l u n d e r s t a n d i n g . The Ecological Perspective M a n y of the t h e o r e t i c a l m o d e l s a n d f r a m e w o r k s p r e s e n t e d h e r e h a v e m i g r a t e d f r o m a m o r e individualistic, d e c o n t e x t u a l i z e d v i e w to a m o r e e c o l o g i c a l v i e w , a c k n o w l e d g i n g the i n f l u e n c e of the e n v i r o n m e n t , both s o c i a l a n d p h y s i c a l , o n p e r s o n a l w e l l - b e i n g . F o r e x a m p l e , the W H O m o d e l s ( W H O , 1 9 8 0 ; W H O , 2 0 0 1 ) h a v e e v o l v e d f r o m a linear a n d restricted r e p r e s e n t a t i o n of the c o n s e q u e n c e s of a health c o n d i t i o n to a n interactive b i o p s y c h o - s o c i a l a p p r o a c h , w h i c h i n c l u d e s the e n v i r o n m e n t a n d p e r s o n a l f a c t o r s a s k e y contributors to the e x p e r i e n c e of a health c o n d i t i o n . D a y s h ( 1 9 9 9 , p.xv) s t a t e s , " H e a l t h e c o l o g y , a s s e s s e d in all its m e a n i n g s , highlights h e a l t h , w h i c h at all t i m e s p r o v i d e s a  25  p e n e t r a t i v e a n d influential t h r e a d " . F o r a c o m p r e h e n s i v e d i s c u s s i o n of health e c o l o g y , s e e H o n a r i a n d B o l e y n (1999). T h e c o n c e p t of e c o l o g y h a s a l s o b e e n d i s c u s s e d f r o m a n a u d i o l o g i c a l p e r s p e c t i v e ; B o r g (1998) r e c o g n i z e s that a u d i o l o g i c a l rehabilitation a n d h a n d i c a p h a v e u s e d ' e c o l o g y ' a s a m e t a p h o r for a n a l y s i s (e.g., F o s t e r & d e C a r o , 1 9 9 1 ; N o b l e , 1 9 8 3 ; N o b l e & H e t u , 1 9 9 4 ) . N o b l e (1983) c o n t r a s t s the p h y s i o l o g i c a l a s p e c t of h e a r i n g l o s s to a n e c o l o g i c a l o n e , w h e r e h e a r i n g is c o n s i d e r e d in t e r m s of its d a y - t o - d a y c h a r a c t e r i s t i c s . H e s u g g e s t s a n a c c e s s i b i l i t y f o c u s of rehabilitation: " R e h a b i l i t a t i o n c o u l d c o m e to m e a n not the r e i n d u c t i o n of the s t i g m a t i z e d into the ' n o r m a l ' w o r l d but the e x p a n s i o n of the n o r m a l w o r l d to a c c o m m o d a t e a larger variety of h u m a n s " ( N o b l e , 1 9 8 3 , p.325). P i c h o r a - F u l l e r ( 1 9 9 4 , p.210) a l s o p r o m o t e s a n e c o l o g i c a l v i e w p o i n t w h e n s h e suggests: " W e n e e d to u n d e r s t a n d h o w the h a n d i c a p e x p e r i e n c e d by i n d i v i d u a l s a n d by g r o u p s is m o d u l a t e d by context: p h y s i c a l context, p s y c h o l o g i c a l context, institutional context, a n d s o c i a l context. Ultimately, w e n e e d to d i s c o v e r w a y s to m a n i p u l a t e t h e s e c o n t e x t s to r e d u c e h a n d i c a p e x p e r i e n c e d by i n d i v i d u a l s a n d g r o u p s . T h i s g o a l w o u l d s u p p l e m e n t or p e r h a p s e v e n r e p l a c e the m o r e typical g o a l of c l i n i c i a n s to r e d u c e the h a n d i c a p e x p e r i e n c e d by i n d i v i d u a l s by treating the individual in i s o l a t i o n . "  B o r g (1998) p r e s e n t s a n i n d e p e n d e n t a p p r o a c h to e c o l o g i c a l a u d i o l o g y a n d p r e s e n t s a c o n c e p t u a l f r a m e w o r k for d e s c r i b i n g a h a n d i c a p resulting f r o m h e a r i n g l o s s in a n a n a l o g y to a b i o l o g i c a l e c o l o g i c a l s y s t e m . G e n e r a l l y , B o r g d e s c r i b e s a n e c o l o g i c a l s y s t e m to b e c o n t i n u o u s l y s u b j e c t e d to f o r c e s that c r e a t e a n i m b a l a n c e in the s y s t e m . A n i n c r e a s e of e n e r g y or n e w material in the e n v i r o n m e n t c a n r e - e s t a b l i s h b a l a n c e , a s c a n a c h a n g e in the s y s t e m a n d a r e - e v a l u a t i o n of p r e f e r e n c e s . T h e p r i m a r y c o n c e p t s of B o r g ' s s y s t e m a r e interaction, r e s o u r c e o p t i m i z a t i o n , internal m i l i e u , a n d p r e f e r e n d u m , or p r e f e r r e d e n v i r o n m e n t , w h i l e the s e c o n d a r y c o n c e p t s a r e b e h a v i o r , signal, and m e s s a g e . (For a c o m p r e h e n s i v e explanation, s e e B o r g , 1998).  His  f r a m e w o r k is f o u n d e d in the traditions of b i o l o g i c a l e c o l o g y , a n d it tries to bring t o g e t h e r the internal a n d e x t e r n a l e n v i r o n m e n t s .  E s s e n t i a l l y , p e r c e i v e d c o m m u n i c a t i o n ability is  c o m p a r e d with d e s i r e d c o m m u n i c a t i o n ability; if t h e s e s i g n a l s a r e e q u a l , the s y s t e m is in b a l a n c e . H o w e v e r , a d i f f e r e n c e in t h e s e s i g n a l s c r e a t e s a h a n d i c a p a n d i n d u c e s a m e n t a l r e s p o n s e . T h e s e p r o c e s s e s m a y l e a d to motivation or c o m p e n s a t i o n in o r d e r to  26 r e g a i n b a l a n c e within the s y s t e m . T h i s m e n t a l r e s p o n s e , e . g . , f e e l i n g of failure, l o s s of c o n f i d e n c e , or a n g e r , is i n f l u e n c e d by n u m e r o u s f a c t o r s s u c h a s interaction, r e c y c l i n g , o p t i m a l u s e of m e n t a l r e s o u r c e s , a n d the p r e f e r r e d e n v i r o n m e n t . c a u s e of the p r o b l e m a s etiological  audiology,  B o r g refers to the  u n d e r s t a n d i n g the c o n s e q u e n c e s of the  h e a r i n g l o s s a n d the i n f l u e n c e o n ability of the individual with h e a r i n g l o s s a s audiology,  a n d the g o a l to r e - e s t a b l i s h b a l a n c e in the s y s t e m a s  ecological  therapeutical  audiology. T h i s p r e v i o u s s e c t i o n d e m o n s t r a t e s , u s i n g e x i s t i n g c o n c e p t u a l f r a m e w o r k s (e.g., B o r g , 1 9 9 8 ) , the i m p o r t a n c e of a n e c o l o g i c a l p e r s p e c t i v e in u n d e r s t a n d i n g h e l p - s e e k i n g b e h a v i o r . T h e f o l l o w i n g s e c t i o n will d e s c r i b e the c o n s e q u e n c e s of h e a r i n g l o s s , p e r s o n a l a n d s o c i a l , f r o m the e m p i r i c a l literature in a u d i o l o g y . Empirical Background  T h e Impact of H e a r i n g L o s s R e v i s i t i n g the c o n s e q u e n c e s of a health c o n d i t i o n , a s i n t r o d u c e d in the W H O m o d e l ( W H O , 1 9 9 8 ) , r e c a l l that t h e r e a r e c a t e g o r i e s relating to b o d y , p e r s o n , a n d s o c i e t y . T h e impairment Activity  is c a t e g o r i z e d by the r e d u c t i o n of a u d i t o r y function at the b o d y l e v e l .  or activity limitation  c o n c e r n s c o n s e q u e n c e s at the p e r s o n l e v e l ; activity refers to  w h a t a p e r s o n d o e s , f r o m s i m p l e activities to c o m p l e x skills a n d b e h a v i o r s . limitation  refers to a difficulty at the l e v e l of the p e r s o n , a n d this c o n c e p t w a s f o r m e r l y  referred to a s disability. Participation  is the interaction of i m p a i r m e n t s , activity  limitations, c o n t e x t u a l f a c t o r s , a n d p e r s o n a l f a c t o r s at the l e v e l of s o c i e t y . restriction  Activity  Participation  is a d i s a d v a n t a g e at this s o c i e t a l l e v e l ; it c a n be a f f e c t e d by c o n t e x t u a l  f a c t o r s , a n d this c o n c e p t w a s f o r m e r l y referred to a s h a n d i c a p . T h i s s e c t i o n will p r e s e n t the e m p i r i c a l f i n d i n g s c o n c e r n i n g h e a r i n g l o s s a s t h e y relate to the b o d y , p e r s o n a l , a n d social levels.  F r o m I m p a i r m e n t to H a n d i c a p A n e a r l y belief of s o m e a u d i o l o g i s t s w a s that d e g r e e of difficulty a d j u s t i n g to a h e a r i n g l o s s c o u l d b e d e t e r m i n e d b y the d e g r e e of i m p a i r m e n t , with the m e a s u r e of i m p a i r m e n t b e i n g the c o r n e r s t o n e of rehabilitative m e a s u r e s . O y e r a n d F r a n k m a n n ( 1 9 7 5 ) r e p o r t e d that e v e n t h o u g h h a n d i c a p w o u l d v a r y a m o n g i n d i v i d u a l s , h a n d i c a p m e a s u r e s c o r r e l a t e d highly with p u r e t o n e a u d i o m e t r y .  H o w e v e r , Hull ( 1 9 9 2 ) later  27  p o i n t e d out that t h o u g h a u d i o m e t r i c d a t a p r o v i d e important information for u n d e r s t a n d i n g a client's p r o b l e m , the a u d i o l o g i s t m u s t b e a w a r e of the limitations of the m e a s u r e s ; he s u g g e s t e d that it is difficult to g e n e r a l i z e f r o m f o r m a l testing to the e v e r y d a y e x p e r i e n c e s of the i n d i v i d u a l . T h e a w a r e n e s s that i m p a i r m e n t did not reliably predict h a n d i c a p led to the d e v e l o p m e n t of q u e s t i o n n a i r e s for the a s s e s s m e n t of c o m m u n i c a t i v e function a s p r o m i s i n g n e w tools to e s t i m a t e d e g r e e of disability a n d h a n d i c a p . T h e r e is a l o n g list of s u c h q u e s t i o n n a i r e s i n c l u d i n g the H e a r i n g - H a n d i c a p S c a l e ( H H S ) ( H i g h , F a i r b a n k s , & G l o r i g , 1 9 6 4 ) , the D e n v e r S c a l e of C o m m u n i c a t i o n F u n c t i o n (Alpiner, C h e v r e t t e , G l a s c o e , M e t z , & O l s e n , 1 9 7 8 ) , the H e a r i n g P e r f o r m a n c e Inventory (HPI) ( G i o l a s , O w e n s , L a m b , & S c h u b e r t , 1 9 7 9 ) , the S e l f - A s s e s s m e n t of C o m m u n i c a t i o n ( S c h o w & N e r b o n n e , 1 9 8 2 ) , H e a r i n g H a n d i c a p Inventory for A d u l t s ( H H I E ) ( N e w m a n , W e i n s t e i n , J a c o b s o n , & H u g , 1 9 9 1 ) , a n d the C o m m u n i c a t i o n Profile for the H e a r i n g Impaired ( C P H I ) ( D e m o r e s t & E r d m a n n , 1 9 8 7 ) . S o m e of t h e s e s c a l e s s t r e s s the attitudes of those w h o are hard-of-hearing while others f o c u s o n c o m m u n i c a t i o n environments; a g e s p e c i f i c q u e s t i o n n a i r e s a l s o s o u g h t to h e l p to identify p r o b l e m a r e a s e x p e r i e n c e d b y particular g r o u p s , for e x a m p l e the H e a r i n g Inventory for the E l d e r l y (Ventry & W e i n s t e i n , 1 9 8 2 ) . N o b l e ( 1 9 9 8 ) p r o v i d e s a c o m p r e h e n s i v e r e v i e w of s e l f - a s s e s s m e n t t o o l s r e l a t e d to a u d i o l o g y . W h i l e t h e s e q u e s t i o n n a i r e s m a y b e a n i m p r o v e m e n t f r o m a s s u m i n g that i n d i v i d u a l s with s i m i l a r i m p a i r m e n t s w o u l d e x p e r i e n c e s i m i l a r h a n d i c a p , t h e r e a r e a l s o s h o r t c o m i n g s of this a p p r o a c h . It is rare for q u e s t i o n n a i r e s to a d e q u a t e l y c a p t u r e the c o m m u n i c a t i o n difficulties e x p e r i e n c e d b y a n individual d u e to the p r e - d e f i n e d p r o b l e m s identified by the q u e s t i o n s , a n d real-life priorities r e m a i n unidentified. A s w e l l , it is d a n g e r o u s to a s s u m e that s u c h h a n d i c a p s c o r e s reflect c o p i n g abilities or rehabilitative g o a l s (Dillon E d g e t t , L a m b , R o o d e n b u r g , P i c h o r a - F u l l e r , & J o h n s o n , 1 9 9 8 ) .  Lormore  a n d S t e p h e n s ( 1 9 9 4 ) a l s o r e p o r t e d that s u b t l e but s o m e t i m e s important difficulties w e r e missed on standard disability/handicap questionnaires b a s e d on s p e e c h perception disability.  Activity H e a r i n g i m p a i r m e n t h a s b e e n s h o w n to affect i n d i v i d u a l s a n d i n t r o d u c e difficulty at the l e v e l of the p e r s o n . E r i k s s o n - M a n g o l d a n d C a r l s s o n ( 1 9 9 1 ) d i s c u s s the  28 p s y c h o l o g i c a l a n d s o m a t i c d i s t r e s s r e l a t e d to p e r c e i v e d h e a r i n g h a n d i c a p ; p e r c e p t i o n of h a n d i c a p c o r r e l a t e s to a g e n e r a l l e v e l of d i s t r e s s , particularly f e e l i n g s of insecurity. T h e s e a u t h o r s s u g g e s t that s t r e s s r e a c t i o n s c o u l d b e i n d u c e d b y a p e r c e i v e d l o s s of control resulting f r o m i n s e c u r i t y a n d r e d u c e d h e a r i n g ability. T h e s e f i n d i n g s a r e c o n s i s t e n t with e a r l i e r f i n d i n g s of E r i k s s o n - M a n g o l d a n d E r l a n d s s o n ( 1 9 8 4 ) , w h o r e p o r t e d that n o r m a l h e a r i n g i n d i v i d u a l s with i n d u c e d h e a r i n g l o s s (through t e m p o r a r y o c c l u s i o n ) r e p o r t e d t e n s i o n , s t r e s s , f e e l i n g s of insecurity, a n d l o s s of control of the situation. D e p r e s s i o n ( G i l h o m e H e r b s t , M e r e d i t h , & S t e p h e n s , 1 9 9 0 ) , i s o l a t i o n , a c c e p t a n c e , a n x i e t y , a w k w a r d n e s s , worry, f e a r , a n d e m b a r r a s s m e n t ( T y e - M u r r a y , 1 9 9 8 ) a r e a l s o reported to result f r o m h e a r i n g l o s s . L u e y , G l a s s , a n d Elliot ( 1 9 9 5 ) a d d r e s s the i s s u e of culture a n d the g r o u p identity of hard-of-hearing v e r s u s Deaf individuals from a social work perspective. T h r o u g h a s e r i e s of i n t e r v i e w s , t h e s e a u t h o r s d e t e r m i n e d that self-definition a s d e a f , D e a f , d e a f e n e d , h a r d - o f - h e a r i n g , or h e a r i n g - i m p a i r e d , is a c o m p l e x i s s u e involving not o n l y l e v e l of h e a r i n g ability, but a l s o c o m m u n i c a t i o n , l a n g u a g e , culture, a n d politics. T h e i m p l i c a t i o n s for s o c i a l w o r k a r e d e s c r i b e d ; for e x a m p l e , the p r i m a r y g o a l for s o c i a l w o r k e r s is to e s t a b l i s h a w a y to c o m m u n i c a t e b a s e d o n w h a t the client k n o w s a n d p r e f e r s . D e p e n d i n g o n t h e c i r c u m s t a n c e s , this m i g h t m e a n f i n d i n g a quiet, well-lit p l a c e to talk, h a v i n g a n o t e p a d to write k e y w o r d s , or p r o v i d i n g a p r o f e s s i o n a l interpreter. T h i s s e c t i o n p r o v i d e s e v i d e n c e of the c o n s e q u e n c e s of h e a r i n g l o s s o n the i n d i v i d u a l . It is a l s o important to a c k n o w l e d g e the c o n s e q u e n c e s of h e a r i n g l o s s o n i n d i v i d u a l s within their context, a n d the next s e c t i o n a d d r e s s e s t h e s e s o c i a l l y interactive consequences. Participation: H o m e T h e s o c i a l i m p l i c a t i o n s of h e a r i n g l o s s a r e f a r - r e a c h i n g , f r o m c o m m u n i t y to o c c u p a t i o n a l , a n d f r o m intimate to f a m i l i a l . T h e a c k n o w l e d g e m e n t of the effect of the e n v i r o n m e n t o n the p e r s o n w i t h h e a r i n g l o s s h a s l e d to a g r e a t e r u n d e r s t a n d i n g of the i m p a c t of h e a r i n g l o s s . R e s e a r c h f i n d i n g s a l s o s h o w that h e a r i n g l o s s i m p a c t s not o n l y the p e r s o n with the i m p a i r m e n t , but a l s o t h o s e w h o interact with h i m or her. J o n e s , K y l e , a n d W o o d ( 1 9 8 7 ) e m p h a s i z e the i m p o r t a n c e of s o c i a l interaction a n d d i s c u s s the effect of mild a n d m o d e r a t e h e a r i n g l o s s a n d c o p i n g with h e a r i n g l o s s in the c o n t e x t of r e l a t i o n s h i p s . M y e r s ( 2 0 0 0 ) a l s o a c k n o w l e d g e s the p r o b l e m s f a c e d by t h o s e  w h o a r e h a r d - o f - h e a r i n g at h o m e a n d at w o r k .  H e r e c o g n i z e s that f a m i l y a n d f r i e n d s of  t h o s e with h e a r i n g l o s s a l s o f a c e a d j u s t m e n t s . L u t e r m a n ( 1 9 9 9 ) a d v o c a t e s a true f a m i l y - c e n t e r e d rehabilitative a p p r o a c h that a d d r e s s e s e m o t i o n a l a s p e c t s of h e a r i n g l o s s , a s h e r e c o g n i z e s the effect of h e a r i n g l o s s o n the f a m i l y . T h r o u g h q u e s t i o n n a i r e a d m i n i s t r a t i o n to patients a n d their significant o t h e r s , S t e p h e n s , F r a n c e , a n d L o r m o r e ( 1 9 9 5 ) f o u n d that, w h i l e i n d i v i d u a l s with h e a r i n g l o s s r e p o r t e d p r o b l e m s of d e p e n d e n c e , the significant o t h e r s c o n c e n t r a t e d m o r e o n difficulties with live s p e e c h a n d p s y c h o s o c i a l difficulties. A s i m i l a r a p p r o a c h b y L o r m o r e a n d S t e p h e n s ( 1 9 9 4 ) f o u n d that significant o t h e r s r e p o r t e d m o r e p r o b l e m s relating to l o u d n e s s of the t e l e v i s i o n a n d r a d i o a n d to p s y c h o s o c i a l a s p e c t s of h e a r i n g l o s s , s u c h a s w i t h d r a w a l a n d u n s o c i a b l e b e h a v i o r s , t h a n t h e i n d i v i d u a l s with h e a r i n g l o s s . P i c h o r a - F u l l e r a n d C a r s o n ( 2 0 0 1 ) r e c o g n i z e that the a c o u s t i c e c o l o g y of f a m i l y a n d f r i e n d s is a l t e r e d a l o n g with that of the individuals w h o are hard-of-hearing. T h e i m p a c t of h e a r i n g l o s s o n intimate r e l a t i o n s h i p s a n d the resulting c o p i n g p r o c e s s w e r e s t u d i e d by H e t u , J o n e s , a n d G e t t y ( 1 9 9 3 ) ; t h e r e s u l t s identify n e e d s for e a c h p a r t n e r r e g a r d i n g i n f o r m a t i o n , s u p p o r t , a n d c o m m u n i c a t i o n facilitation. C o n s i d e r a t i o n f r o m both p e r s p e c t i v e s is important b e c a u s e both the h e a r i n g a n d t h e i n d i v i d u a l s with h e a r i n g l o s s a r e e x p e r i e n c i n g t h e h e a r i n g l o s s , but t h e y v i e w the p r o b l e m f r o m different perspectives. E r d m a n ( 2 0 0 0 ) s u g g e s t s that c l i n i c i a n s c a n h e l p e a s e t e n s i o n b y p r o v i d i n g information a b o u t h e a r i n g i m p a i r m e n t , e v a l u a t i n g the d i s p a r a t e v i e w s of participating p a r t i e s , identifying c o m m o n g r o u n d , a n d offering potential e x p l a n a t i o n s for t h e different e x p e r i e n c e s . G r o u p c o u n s e l i n g c a n p r o v i d e t h e opportunity for c o u p l e s to o b s e r v e that o t h e r f a m i l i e s s t r u g g l e with s i m i l a r i s s u e s . H a l l b e r g ( 1 9 9 6 ) a n d A b r a h a m s o n ( 1 9 9 1 ) b e l i e v e that s p o u s e o r family i n v o l v e m e n t is vital to the s u c c e s s of a u d i o l o g i c a l rehabilitation p r o g r a m s . E r b e r h a s d e v e l o p e d rehabilitative m e t h o d s to p r o v i d e t h e r a p y for both t h e i n d i v i d u a l s with h e a r i n g l o s s a n d their c o m m u n i c a t i o n p a r t n e r s ( E r b e r , 1 9 8 8 , 1993).  Participation: Work H e a r i n g l o s s affects i n d i v i d u a l s in their o c c u p a t i o n a l e n v i r o n m e n t .  Kyle and W o o d  ( 1 9 8 5 ) f o u n d that t h e v o c a t i o n a l c o n s e q u e n c e s of a c q u i r e d h e a r i n g l o s s i n c l u d e g r e a t e r a n x i e t y , f e w e r p r o m o t i o n o p p o r t u n i t i e s , a n d r e d u c e d participation with g r o u p w o r k  30 activities. H e t u , G e t t y , a n d c o l l e a g u e s report that h e a r i n g l o s s is often c o n c e a l e d a n d d e m a n d i n g s i t u a t i o n s a r e a v o i d e d , i m p o s i n g self-restriction o n c a r e e r a d v a n c e m e n t (for example, s e e Getty & Hetu, 1994; Hetu & Getty, 1993; Hetu, Riverin, Getty, Lalande, & S t - C y r , 1 9 9 0 ) . Industrial w o r k e r s report t h e m s e l v e s to b e s t r o n g l y s t i g m a t i z e d a s b e i n g d e a f e s p e c i a l l y by c o - w o r k e r s , a n d their r e l u c t a n c e to a c k n o w l e d g e h e a r i n g difficulties w a s e x p r e s s e d t h r o u g h v a r i o u s f o r m s of d e n i a l , m i n i m i z a t i o n of the p r o b l e m , u n e a s i n e s s in talking a b o u t the p r o b l e m , a n d in a t t e m p t s to n o r m a l i z e the self. T h e s e o c c u p a t i o n a l i m p l i c a t i o n s of h e a r i n g a l s o affect t h o s e at h o m e . H e t u , L a l o n d e , a n d G e t t y ( 1 9 8 7 ) d i s c u s s the effect of o c c u p a t i o n a l h e a r i n g l o s s o n the individual with h e a r i n g l o s s , a n d report that the family e x p e r i e n c e s c o n s e q u e n c e s of n o i s e e x p o s u r e a n d of the h e a r i n g l o s s of the w o r k e r . T h e r e is a l s o e v i d e n c e that m a n y e m p l o y e e s with h e a r i n g l o s s h a v e difficulty c o p i n g w i t h full-time e m p l o y m e n t ( B a c k e n r o t h & A h l n e r , 1 9 9 7 ) ; this s t u d y a l s o i n d i c a t e d that the o c c u p a t i o n a l i m p l i c a t i o n s of h e a r i n g l o s s a r e m a i n l y a s s o c i a t e d with s o c i a l i n t e r a c t i o n s with o t h e r s in the w o r k p l a c e . T h i s s e c t i o n h a s i n t r o d u c e d e v i d e n c e of the c o n s e q u e n c e s of h e a r i n g l o s s o n a participation l e v e l . T h e following s e c t i o n i n t r o d u c e s the f i n d i n g s of e x i s t i n g h e l p - s e e k i n g literature r e l e v a n t to the current s t u d y . Help-Seeking T h e r e h a v e b e e n s t u d i e s that e x a m i n e d h e l p - s e e k i n g for h e a r i n g l o s s . M a n y of t h e s e s t u d i e s f o c u s o n the elderly p o p u l a t i o n a n d its initial c o n s u l t a t i o n for a h e a r i n g l o s s o r o b t a i n i n g a h e a r i n g a i d . W h e r e a p e r s o n is in t e r m s of a d j u s t m e n t to h e a r i n g l o s s is a n important c o n s i d e r a t i o n . T y e - M u r r a y ( 1 9 9 8 ) reports that J o n e s , K y l e , a n d W o o d ( 1 9 8 7 ) identified four p h a s e s in the time c o u r s e of a c q u i r e d h e a r i n g l o s s : p r e - h e a r i n g l o s s o n s e t , o n s e t of h e a r i n g l o s s , d i a g n o s i s , a n d a d j u s t m e n t .  R e g a r d i n g the first p h a s e (pre-  h e a r i n g l o s s ) , f e w p e o p l e a n t i c i p a t e a h e a r i n g l o s s a n d it is u s u a l l y a s u r p r i s e w h e n it b e g i n s . T h e time f r o m o n s e t to d i a g n o s i s c a n e x t e n d for a lengthy p e r i o d of time (for a r e v i e w , s e e C a r s o n , 2 0 0 0 ) ; d u r i n g this time m a n y i n d i v i d u a l s b l a m e the s p e a k e r a n d e n v i r o n m e n t a l f a c t o r s for their inability to c o m m u n i c a t e a s t h e y u s e d to. A t this point, m a n y i n d i v i d u a l s will d i s c u s s the i s s u e with o t h e r s c l o s e to t h e m , a s d e s c r i b e d a b o v e in the d i s c u s s i o n of s o c i a l c o m p a r i s o n s . In the third s t a g e , d i a g n o s i s , a p r o f e s s i o n a l identifies a n d d i a g n o s e s the h e a r i n g l o s s . A n x i e t y is a c o m m o n r e a c t i o n at this s t a g e ; h o w e v e r , the length of time d u r i n g w h i c h a h e a r i n g l o s s w a s s u s p e c t e d m a y m e d i a t e  t h e s e n e g a t i v e e m o t i o n a l r e a c t i o n s ( T y e - M u r r a y , 1 9 9 8 ) . In the final s t a g e of a d j u s t m e n t , i n d i v i d u a l s a d a p t to h e a r i n g l o s s . T h i s a d a p t a t i o n m a y result f r o m c o u n s e l i n g , h e a r i n g a i d s , a s s i s t i v e d e v i c e s , or b e h a v i o r a l rehabilitation. T y e - M u r r a y a l s o r e c o g n i z e s the m o n e t a r y a n d n o n - m o n e t a r y c o s t s r e l a t e d to the a d j u s t m e n t p h a s e ; in a d d i t i o n to the c o s t of the a m p l i f i c a t i o n d e v i c e , t r a n s p o r t a t i o n , lost w a g e s a n d o t h e r monetary i s s u e s , 'psychic' c o s t s include: a c c e p t a n c e , anxiety, a w k w a r d n e s s , worry, fear, a n d e m b a r r a s s m e n t . P s y c h o s o c i a l w e l l - b e i n g a n d v o c a t i o n a l s t a t u s a r e o t h e r i s s u e s of i m p o r t a n c e relative to the a d j u s t m e n t p h a s e ( M c C o r m i c k et a l . , 1 9 9 4 ) . v a n d e n Brink, Wit, K e m p e n , a n d v a n H e u v e l e n ( 1 9 9 6 ) e x a m i n e d attitude a n d h e l p s e e k i n g for h e a r i n g i m p a i r m e n t . T h e i r r e s e a r c h , w h i c h f o c u s e d o n e l d e r l y s u b j e c t s , f o u n d that t h o s e w h o did not c o n s u l t for h e a r i n g l o s s p e r c e i v e d their i m p a i r m e n t a s i n c o n s e q u e n t i a l , d e m o n s t r a t e d a p a s s i v e a c c e p t a n c e of t h e l o s s with i n c r e a s i n g a g e , a n d e x p e r i e n c e d little p r e s s u r e f r o m o t h e r s to s e e k h e l p . Individuals w h o c o n s u l t e d a d o c t o r but did not o b t a i n a m p l i f i c a t i o n r e p o r t e d the g r e a t e s t s t i g m a - r e l a t e d b a r r i e r s to the u s e of h e a r i n g a i d s . F i n a l l y , v a n d e n Brink a n d c o l l e a g u e s r e p o r t e d that the m o s t f a v o r a b l e attitude t o w a r d h e a r i n g a i d s w a s o b t a i n e d f r o m t h o s e i n d i v i d u a l s currently using hearing aids. G i l h o m e H e r b s t , M e r e d i t h , a n d S t e p h e n s ( 1 9 9 0 ) , w h o a l s o f o c u s o n e l d e r s , report that t h e s o c i a l i m p l i c a t i o n s of h e a r i n g l o s s affect h e l p - s e e k i n g activity; p o o r insight into the e x i s t e n c e of h e a r i n g l o s s , d e n i a l of the l o s s , l a c k of s u p p o r t f r o m d o c t o r s , a n d r e d u c e d activities out of t h e h o m e a f f e c t e d the d e s i r e to o b t a i n h e l p . M a h o n e y , S t e p h e n s , a n d C a d g e ( 1 9 9 6 ) r e p o r t e d that f e w c l i e n t s w e r e s e l f - m o t i v a t e d to s e e k h e l p for h e a r i n g l o s s ; m o r e often, the p e r s u a s i o n of a family m e m b e r w a s t h e i m p e t u s for h e l p - s e e k i n g , e s p e c i a l l y for s e n i o r p a r t i c i p a n t s . P a r k e r ( 2 0 0 1 ) s t u d i e d t h e effects of c o s t , n e e d , a n d r e l a t i o n s h i p strength o n h e l p - s e e k i n g ; r e s u l t s i n d i c a t e that o p t i m a l h e l p s e e k i n g c o n d i t i o n s e x i s t w h e n the c o s t to the potential h e l p e r is low, t h e n e e d of the potential h e l p - s e e k e r w a s h i g h , a n d the r e l a t i o n s h i p b e t w e e n the s e e k e r a n d p r o v i d e r w a s s t r o n g . T h e s e c o n d i t i o n s l e a d to a m o r e d i r e c t c o u r s e of h e l p - s e e k i n g a n d g r e a t e r l i k e l i h o o d of the h e l p - s e e k i n g b e h a v i o r . L a l a n d e , R i v e r i n , a n d L a m b e r t ( 1 9 8 8 ) d e s c r i b e a trial rehabilitation p r o g r a m d e s i g n e d s p e c i f i c a l l y for w o r k e r s with o c c u p a t i o n a l h e a r i n g l o s s a n d their s p o u s e s , i n c l u d i n g a c o n s i d e r a t i o n of the f a c t o r s c a u s i n g c l i e n t s to s e e k or a v o i d p r o f e s s i o n a l a s s i s t a n c e . Q u e s t i o n n a i r e r e s u l t s i n d i c a t e d that t h e m a i n f a c t o r s l e a d i n g to e n r o l l m e n t in t h e  p r o g r a m w e r e a c k n o w l e d g e m e n t of a significant h a n d i c a p , r e c o g n i t i o n of n e e d for h e l p with tinnitus a n d s t r e s s , a n d n e e d to u s e s t r a t e g i e s to facilitate c o m m u n i c a t i o n .  Lalande  a n d c o l l e a g u e s r e c o g n i z e d a l o w e n r o l l m e n t in t h e p r o g r a m a n d s u g g e s t that for this p o p u l a t i o n of e m p l o y e e s with n o i s e - i n d u c e d h e a r i n g l o s s , t h e r e is a n e e d for: (1) A m o r e well d e f i n e d target p o p u l a t i o n , (2) S t r a t e g i e s to p r o m o t e g r e a t e r u n d e r s t a n d i n g , a w a r e n e s s , a n d a c c e p t a n c e of h e a r i n g h a n d i c a p o n the part of o c c u p a t i o n a l h e a r i n g l o s s workers and people surrounding them, (3) E d u c a t i o n at the w o r k p l a c e a n d in s o c i e t y in g e n e r a l to i n c r e a s e motivation a n d a w a r e n e s s of the b e n e f i t s of a u r a l rehabilitation s e r v i c e s , (4) Integration of the p r o g r a m within the g e n e r a l h e a l t h p r o g r a m in the work place, (5) M e a s u r e s to e n h a n c e the credibility of p r o f e s s i o n a l s in the rehabilitation s e r v i c e s , (6) G e n e r a l a n d s p e c i f i c p r o g r a m s a n d f o l l o w - u p s e r v i c e s , a n d (7) M o r e a c c e s s i b l e s e r v i c e s . ( L a l a n d e et a l . , 1 9 8 8 , p.248) T h i s s e c t i o n r e v i e w e d the h e l p - s e e k i n g literature a s it h a s b e e n s t u d i e d r e g a r d i n g h e l p - s e e k i n g for h e a r i n g l o s s . T h i s w o r k p r o v i d e s a n important f o u n d a t i o n for the current s t u d y , but s h o w s that a d d i t i o n a l r e s e a r c h is n e e d e d to fully u n d e r s t a n d t h e h e l p s e e k i n g b e h a v i o r for i n d i v i d u a l s w h o a r e h a r d - o f - h e a r i n g , particularly r e g a r d i n g participation in g r o u p h e a r i n g rehabilitation p r o g r a m s . Qualitative R e s e a r c h M e t h o d o l o g i c a l c o n s i d e r a t i o n s r e l e v a n t to the current s t u d y will b e d i s c u s s e d in C h a p t e r 3 . T h i s s e c t i o n will r e v i e w qualitative s t u d i e s r e l e v a n t to this r e s e a r c h s t u d y . A limited n u m b e r of qualitative s t u d i e s h a v e b e e n c o n d u c t e d in t h e a u d i o l o g i c a l a r e n a ; h o w e v e r , t h o s e qualitative s t u d i e s h a v e p r o v i d e d v a l u a b l e insights into the e x p e r i e n c e a n d m e a n i n g of h e a r i n g l o s s . H e t u , G e t t y , a n d c o l l e a g u e s at the U n i v e r s i t y of M o n t r e a l h a v e c o n d u c t e d a s e r i e s of qualitative s t u d i e s that a t t e m p t to u n d e r s t a n d the e x p e r i e n c e of w o r k e r s with o c c u p a t i o n a l h e a r i n g l o s s (Getty et a l . , 1 9 9 6 ; G e t t y & H e t u , 1 9 9 4 ; H e t u , G e t t y , & W r i d e l , 1 9 9 4 ; H e t u et a l . , 1 9 9 3 ; H e t u , R i v e r i n , L a l a n d e , & S t . - C y r , 1 9 8 8 ) ; this w o r k c o n c e n t r a t e d primarily o n a p h e n o m e n o l o g i c a l a p p r o a c h . In a n effort to d e t e r m i n e if t h e r e is a culture of h a r d - o f - h e a r i n g w o r k e r s , G e t t y a n d H e t u ( 1 9 9 4 ) c o n c l u d e d that this culture d o e s not exist d u e to t h e r e l u c t a n c e to d i s c l o s e h e a r i n g l o s s . T h i s s t u d y a l s o s u g g e s t e d that s t i g m a d e t e r m i n e s the l e v e l of c o p i n g a n d that the s u p p o r t of the s p o u s e is vital in the p r o c e s s of p r o b l e m s o l v i n g .  A g r o u p from S w e d e n h a s s t u d i e d h e a r i n g i m p a i r m e n t , h e a r i n g h a n d i c a p , c o p i n g , a n d the c o n s e q u e n c e s of h e a r i n g l o s s o n f a m i l y life ( H a l l b e r g , 1 9 9 9 ; H a l l b e r g & C a r l s s o n , 1 9 9 1 , 1 9 9 3 ) , u s i n g primarily g r o u n d e d t h e o r y m e t h o d o l o g y . H a l l b e r g a n d C a r l s s o n ( 1 9 9 1 ) d e s c r i b e d c o p i n g f r o m the p e r s p e c t i v e of their p a r t i c i p a n t s w h o w e r e h a r d - o f - h e a r i n g . T w o p a tte rn s e m e r g e d f r o m the d a t a to reflect qualitatively different m a n a g e m e n t p a t t e r n s : control the s o c i a l s c e n e a n d a v o i d t h e s o c i a l s c e n e . C o n t r o l l i n g the s o c i a l s c e n e w a s s e e n a s a n a c t i v e a n d c o n s t r u c t i v e w a y of h a n d l i n g difficult listening s i t u a t i o n s a n d c a p t u r e d the qualitative c a t e g o r i e s of structuring the s i t u a t i o n , controlling the e n v i r o n m e n t , striving to m a i n t a i n i n t e r a c t i o n s , a n d u s i n g both v e r b a l a n d n o n v e r b a l s t r a t e g i e s . A v o i d i n g the s o c i a l s c e n e referred to s t r a t e g i e s s u c h a s a v o i d i n g i n t e r a c t i o n s , m i n i m i z i n g the disability, a n d u s i n g invisible n o n - v e r b a l s t r a t e g i e s . T h i s a v o i d a n c e w a s interpreted a s a m e a n s to m a i n t a i n a n o r m a l s o c i a l identity.  Individuals  a d o p t a variety of c o p i n g s t r a t e g i e s but a p p e a r to h a v e a p r e f e r e n c e for either controlling or a v o i d i n g b e h a v i o r s . H a l l b e r g a n d C a r l s s o n ( 1 9 9 3 ) d e s c r i b e d t h e nature of s t r e s s f u l s i t u a t i o n s , f r o m t h e point of v i e w of their p a r t i c i p a n t s with h e a r i n g l o s s , to g a i n a n u n d e r s t a n d i n g of t h e h a n d i c a p c r e a t i o n p r o c e s s . T h e f i n d i n g s r e v e a l e d eight c a t e g o r i e s of qualitatively different s i t u a t i o n s w h e r e disability t u r n e d into h a n d i c a p . T h e s e c a t e g o r i e s c o u l d b e g r o u p e d into t w o c o n c e p t s : s i t u a t i o n s related to the e n v i r o n m e n t a n d s i t u a t i o n s related to life h a b i t s . T h e s e c o n c e p t s w e r e b e l i e v e d to interact with the h e a r i n g i m p a i r m e n t to c r e a t e h a n d i c a p . H a l l b e r g ( 1 9 9 9 ) s u m m a r i z e d the e a r l i e r s t u d i e s , d i s c u s s e d the c o n s e q u e n c e s of h e a r i n g l o s s o n the s p o u s e , a n d integrated the f i n d i n g s into a f a m i l y p e r s p e c t i v e o n rehabilitation. A s m a l l n u m b e r of qualitative s t u d i e s h a v e a l s o e x a m i n e d the e x p e r i e n c e of p a r t i c i p a n t s in a u r a l rehabilitation p r o g r a m s . Israelite a n d J e n n i n g s ( 1 9 9 5 ) e x p l o r e d the p e r s p e c t i v e s of f o u r a d u l t s r e g a r d i n g their e x p e r i e n c e of h e a r i n g l o s s in a g r o u p rehabilitation p r o g r a m . T h e m a j o r t h e m e to e m e r g e f r o m t h e s e d a t a w a s that of a d j u s t i n g to h e a r i n g l o s s a n d t h e c a t e g o r i e s w e r e : identifying becoming perceptions  aware,  losing  control of communication,  of the group experience,  a n d accepting  as  communication hearing  loss.  hard-of-hearing, strategies, T h e s e a u t h o r s report  e v i d e n c e of l o n g - t e r m a n d s h o r t - t e r m a d j u s t m e n t a s w e l l a s i s s u e s of c o n t r o l . F u r t h e r m o r e , B a c k e n r o t h a n d A h l n e r ( 2 0 0 0 ) r e p o r t e d o n t h e quality of life p o s t rehabilitation p r o g r a m . R e s u l t s d e m o n s t r a t e d i n c r e a s e d a w a r e n e s s of t h e h e a r i n g l o s s ,  i n c r e a s e d d e m a n d s o n o t h e r s to u n d e r s t a n d , a n d i n f l u e n c e o n attitude r e g a r d i n g t h e hearing impairment.  P a r t i c i p a n t s r e p o r t e d i n c r e a s e d s e l f - c o n f i d e n c e a n d a n i n c r e a s e in  c o m f o r t in the u s e of c o p i n g s t r a t e g i e s a n d h e a r i n g a i d u s a g e . G e t t y , G a g n e , a n d M c D u f f ( 1 9 9 6 ) d e s c r i b e d the p r o b l e m s r e l a t e d to s e e k i n g h e l p for h e a r i n g l o s s with s e n i o r s , a n d identified m a n y p e r s o n a l a n d s o c i a l i s s u e s a s o b s t a c l e s to h e l p - s e e k i n g . R e c e n t l y , C a r s o n ( 2 0 0 0 ) e x p l o r e d the p e r s p e c t i v e s of o l d e r w o m e n a n d the links b e t w e e n the e x p e r i e n c e of living with a h e a r i n g l o s s a n d the p r o c e s s of h e l p - s e e k i n g in t e r m s of m a k i n g a n initial a p p o i n t m e n t with a n a u d i o l o g i s t . M a n y p e o p l e w h o a r e h a r d - o f - h e a r i n g wait y e a r s b e f o r e t a k i n g t h e first s t e p to d e a l with a h e a r i n g l o s s a n d s u b s e q u e n t l y , m a y wait l o n g e r to t a k e further a c t i o n b a s e d o n the h e a r i n g test r e s u l t s . T h e f i n d i n g s of C a r s o n ' s s t u d y i n d i c a t e that a s e l f - a s s e s s i n g p r o c e s s o c c u r s b e f o r e , d u r i n g , a n d after s e e k i n g h e l p . T h r e e t h e m e s w e r e identified a s significant in this p r o c e s s : contrasting performing seeking  cost versus  efforts.  and comparing benefit analyses,  hearing  against  a n d perceiving  a variety of  yardsticks,  a loss of control related  to help-  T h i s s t u d y r e p r e s e n t s a n important contribution to the u n d e r s t a n d i n g of  h e l p - s e e k i n g of p e o p l e w h o a r e h a r d - o f - h e a r i n g a n d the r e l a t i o n s h i p b e t w e e n client a n d a u d i o l o g i s t . C a r s o n ' s f i n d i n g s s u g g e s t i m p r o v e m e n t s to a u d i o l o g y s e r v i c e d e l i v e r y a n d the m a j o r i s s u e s in n e e d of c h a n g e i n c l u d e : l e s s f o c u s o n t h e m e a s u r e m e n t of i m p a i r m e n t , l e s s of a n e x p e c t a t i o n of s p e e d y rehabilitative s o l u t i o n s , a n d l e s s f o c u s o n the h e a r i n g a i d a s the m a i n tool of the rehabilitation p r o c e s s .  R a t i o n a l e for A p p r o a c h to C u r r e n t S t u d y  H e l p - s e e k i n g for H e a r i n g L o s s W h y don't m o r e i n d i v i d u a l s utilize g r o u p h e a r i n g rehabilitation p r o g r a m s ?  Pichora-  F u l l e r a n d S c h o w (2002) p r o v i d e insight into this p r o b l e m relative to a b r o a d e r definition of a u r a l rehabilitation. T h e y s u g g e s t that m o s t a d u l t s e x p e r i e n c e g r a d u a l h e a r i n g l o s s a s a result of the a g i n g p r o c e s s ; a s m e n t i o n e d p r e v i o u s l y , a d e l a y in h e l p - s e e k i n g is c o m m o n . H o w e v e r , r e s e a r c h in this a r e a is l a c k i n g . A s m a l l n u m b e r of s t u d i e s h a v e c o m p a r e d a d u l t s w h o h a v e c o n s u l t e d for h e a r i n g l o s s , c o m p a r e d to t h o s e w h o h a v e not ( M a h o n e y et a l . , 1 9 9 6 ; S w a n & G a t e h o u s e , 1 9 9 0 ; v a n d e n Brink et a l . , 1 9 9 6 ) . N e e d s v a r y with t h e p o p u l a t i o n b e c a u s e of d i f f e r e n c e s in e n v i r o n m e n t a l a n d p e r s o n a l f a c t o r s , a n d s u c h d i f f e r e n c e s likely p l a y a role in h e l p - s e e k i n g t o o . S p e c i f i c p o p u l a t i o n s a n d  35 their rehabilitative n e e d s h a v e b e e n d o c u m e n t e d : industrial w o r k e r s (Getty & H e t u , 1 9 9 4 ) , s e n i o r s in c a r e facilities ( P i c h o r a - F u l l e r & R o b e r t s o n , 1 9 9 4 ) , y o u t h a n d university p o p u l a t i o n s ( M c C o r m i c k et a l . , 1 9 9 4 ; W a r i c k , 1 9 9 4 ) , a n d i n m a t e s in p e n i t e n t i a r i e s ( D a h l , 1 9 9 4 ) . H o w e v e r , this e x i s t i n g r e s e a r c h d o e s not e x a m i n e w h y t h e s e i n d i v i d u a l s b e g i n to s e e k h e l p w h e n they d o . P i c h o r a - F u l l e r a n d S c h o w ( 2 0 0 2 , p.357) a l s o d i s c u s s that "the p r e s s i n g n e e d to c o n s i d e r a d j u s t m e n t to h e a r i n g l o s s a s a d