Acquired adult‐onset hearing loss is a common long‐term condition for which the most
common intervention is hearing aid fitting. However, up to 40% of people fitted with
a hearing aid either fail to use it or may not gain optimal benefit from it. This
is an update of a review first published in The Cochrane Library in 2014. To assess
the long‐term effectiveness of interventions to promote the use of hearing aids in
adults with acquired hearing loss fitted with at least one hearing aid. The Cochrane
ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register
of Controlled Trials (CENTRAL 2016, Issue 5); PubMed; EMBASE; CINAHL; Web of Science;
ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials.
The date of the search was 13 June 2016. We included randomised controlled trials
(RCTs) of interventions designed to improve or promote hearing aid use in adults with
acquired hearing loss compared with usual care or another intervention. We excluded
interventions that compared hearing aid technology. We classified interventions according
to the 'chronic care model' (CCM). The primary outcomes were hearing aid use (measured
as adherence or daily hours of use) and adverse effects (inappropriate advice or clinical
practice, or patient complaints). Secondary patient‐reported outcomes included quality
of life, hearing handicap, hearing aid benefit and communication. Outcomes were measured
over the short (</= 12 weeks), medium (> 12 to < 52 weeks) and long term (one year
plus). We used the standard methodological procedures expected by Cochrane. We included
37 studies involving a total of 4129 participants. Risk of bias across the included
studies was variable. We judged the GRADE quality of evidence to be very low or low
for the primary outcomes where data were available. The majority of participants were
over 65 years of age with mild to moderate adult‐onset hearing loss. There was a mix
of new and experienced hearing aid users. Six of the studies (287 participants) assessed
long‐term outcomes. All 37 studies tested interventions that could be classified using
the CCM as self‐management support (ways to help someone to manage their hearing loss
and hearing aid(s) better by giving information, practice and experience at listening/communicating
or by asking people to practise tasks at home) and/or delivery system design interventions
(just changing how the service was delivered). Self‐management support interventions
We found no studies that investigated the effect of these interventions on adherence,
adverse effects or hearing aid benefit. Two studies reported daily hours of hearing
aid use but we were unable to combine these in a meta‐analysis. There was no evidence
of a statistically significant effect on quality of life over the medium term. Self‐management
support reduced short‐ to medium‐term hearing handicap (two studies, 87 participants;
mean difference (MD) ‐12.80, 95% confidence interval (CI) ‐23.11 to ‐2.48 (0 to 100
scale)) and increased the use of verbal communication strategies in the short to medium
term (one study, 52 participants; MD 0.72, 95% CI 0.21 to 1.23 (0 to 5 scale)). The
clinical significance of these statistical findings is uncertain. It is likely that
the outcomes were clinically significant for some, but not all, participants. Our
confidence in the quality of this evidence was very low. No self‐management support
studies reported long‐term outcomes. Delivery system design interventions These interventions
did not significantly affect adherence or daily hours of hearing aid use in the short
to medium term, or adverse effects in the long term. We found no studies that investigated
the effect of these interventions on quality of life. There was no evidence of a statistically
or clinically significant effect on hearing handicap, hearing aid benefit or the use
of verbal communication strategies in the short to medium term. Our confidence in
the quality of this evidence was low or very low. Long‐term outcome measurement was
rare. Combined self‐management support/delivery system design interventions One combined
intervention showed evidence of a statistically significant effect on adherence in
the short term (one study, 167 participants, risk ratio (RR) 1.06, 95% CI 1.00 to
1.12). However, there was no evidence of a statistically or clinically significant
effect on daily hours of hearing aid use over the long term, or the short to medium
term. No studies of this type investigated adverse effects. There was no evidence
of an effect on quality of life over the long term, or short to medium term. These
combined interventions reduced hearing handicap in the short to medium term (14 studies,
681 participants; standardised mean difference (SMD) ‐0.26, 95% CI ‐0.50 to ‐0.02).
This represents a small‐moderate effect size but there is no evidence of a statistically
significant effect over the long term. There was evidence of a statistically, but
not clinically, significant effect on long‐term hearing aid benefit (two studies,
69 participants, MD 0.30, 95% CI 0.02 to 0.58 (1 to 5 scale)), but no evidence of
an effect over the short to medium term. There was evidence of a statistically, but
not clinically, significant effect on the use of verbal communication strategies in
the short term (four studies, 223 participants, MD 0.45, 95% CI 0.15 to 0.74 (0 to
5 scale)), but not the long term. Our confidence in the quality of this evidence was
low or very low. We found no studies that assessed the effect of other CCM interventions
(decision support, the clinical information system, community resources or health
system changes). There is some low to very low quality evidence to support the use
of self‐management support and complex interventions combining self‐management support
and delivery system design in adult auditory rehabilitation. However, effect sizes
are small. The range of interventions that have been tested is relatively limited.
Future research should prioritise: long‐term outcome assessment; development of a
core outcome set for adult auditory rehabilitation; and study designs and outcome
measures that are powered to detect incremental effects of rehabilitative healthcare
system changes. Interventions to improve hearing aid use in adult auditory rehabilitation
Review question We wanted to know if any interventions help people to wear their hearing
aids more. We measured effects over the short term (less than 12 weeks), medium term
(from 12 to 52 weeks) and long term (one year plus). This is an update of a review
first published in The Cochrane Library in 2014. Background Hearing loss is very
common. People who get hearing loss as adults are often offered a hearing aid(s).
However, up to 40% of people fitted with a hearing aid choose not to use it. Study
characteristics The evidence is up to date as of June 2016. We found 37 studies involving
a total of 4129 people. Most of the people in the studies were aged over 65. There
was a mix of new and experienced hearing aid users. Seven studies funded by the United
States Veterans Association dominate the evidence. The 1297 people in these studies
were serving in the military or military veterans. All but two of the other studies
included fewer than 100 people in each study. Results Thirty‐three of the 37 studies
looked at ways to help someone to manage their hearing loss and hearing aid(s) better
by giving information, practice and experience at listening/communicating or by asking
people to practise tasks at home. These are forms of self‐management support. Most
of these studies also changed how the self‐management support was provided, for example
by changing the number of appointment sessions or using telephone or email follow‐up.
Six studies looked at the effect of just changing how the service was delivered. No
studies looked at the effect of using guidelines or standards, computerised medical
record systems, community resources or changing the health system. We found no evidence
that the interventions helped people to wear their hearing aids for more hours per
day over the short, medium or long term. One study that used interactive videos to
give information after hearing aid fitting encouraged more people to wear their hearing
aids. We found no evidence of adverse effects of any of the interventions, but it
was rare for studies to look for adverse effects. Giving self‐management support meant
that people reported less hearing handicap and improved verbal communication over
the short term. When this was combined with changing how the support was delivered
people also reported slightly more hearing aid benefit over the long term. Only six
studies (287 people) looked at how people were doing after a year or more. Conclusions
Complex interventions that deliver self‐management support in different ways improve
some outcomes for some people with hearing loss who use hearing aids. We found no
interventions that increased self‐reported daily hours of hearing aid use. Few studies
measured how many people use hearing aids compared to how many are fitted (adherence).
Many things that might increase daily hours of hearing aid use or encourage more people
to wear the hearing aids they have been fitted with have not been tested. It was difficult
to combine data across different studies because many outcome measures were used and
results were not always fully reported. In future it would be helpful if researchers:
‐ used existing guidelines for presenting their results; ‐ agreed a set of outcome
measures for use in this type of study; and ‐ focused on long‐term outcomes where
people are followed up for at least a year. Quality of the evidence We judged the
evidence to be of very low or low quality. There was risk of bias in the way many
of the studies were carried out or reported. The largest studies included only military
veterans. We do not know whether studies would find the same results in more mixed
populations. Most of the other studies had small sample sizes. Very few studies measured
long‐term outcomes.