Abstract
Objective:
Describe how the Revised Hearing Handicap Inventory (RHHI) changes over time and determine associated factors.
Design:
Data were from a community-based cohort study. Linear regression models were used to estimate mean baseline and final RHHI scores and change (final minus baseline score). Logistic regression models were used to determine factors associated with substantial RHHI change, defined as ±6 points. Factors included baseline age, sex, race, hearing aid use, and baseline pure-tone average (PTA; 0.5, 1.0, 2.0, 4.0 kHz, worse ear).
Study sample:
This study included 583 participants (mean age: 66.4 [SD 9.1] years; 59.9% female; 14.2% Minority race) with a mean follow-up time of 7.6 (SD 4.9) years.
Results:
Baseline and final RHHI scores were 7.9 and 9.2 points, corresponding to an average 1.3-point increase in hearing difficulty over time. Most participants (65.4%) did not show substantial RHHI change, whereas 21.4% and 13.2% experienced substantial increase and decrease, respectively. In separate multivariable models, PTA and hearing aid use were associated with substantial increase in hearing difficulty, and PTA was associated with substantial decrease.
Conclusions:
The average RHHI change was relatively small. Hearing aid use and PTA were associated with RHHI change.
Keywords: demographics/epidemiology, self-report, hearing loss, hearing aids, cohort study
INTRODUCTION
The benefits of measuring self-reported hearing handicap or difficulty are well-recognized among clinicians and researchers. Self-reported hearing difficulty captures the functional impacts of hearing loss on individuals and can predict important outcomes such as hearing aid uptake or use (Hickson et al., 2008; Gopinath et al., 2012; Weycker et al., 2021; Dillard et al., 2021; Dillard et al., 2024a). The Revised Hearing Handicap Inventory (RHHI) is a tool that measures hearing difficulty and was adapted from the widely used Hearing Handicap Inventory for the Elderly (HHIE) and Adults (HHIA) [HHIE/A]. The RHHI is an 18-item, psychometrically robust tool that contains a subset of questions that are also on the HHIE/A. One benefit of the RHHI is that it can be administered to adults of all ages, whereas the HHIE and HHIA are administered to older and younger adults, respectively (Ventry & Weinstein, 1982; Newman et al., 1990; Cassarly et al., 2020). These self-report tools of hearing difficulty are commonly used in research and in clinical settings. Despite their common use, little is known about how these measures change over time in samples of the general population, and how these changes may be influenced by demographic and hearing-related factors. Such data, for example, could inform clinicians and researchers whether changes to self-reported hearing difficulty experienced by individuals are within expected amounts of change, and furthermore, could inform researchers’ and clinicians’ understanding on the factors related to change.
Pure-tone audiometric testing is another important measure of hearing that is used clinically and in some studies of the general population and is often treated as the ‘gold standard’ measure of hearing detection (e.g., Gates et al., 1990; Pearson et al., 1996; Cruickshanks et al., 1998; Lee et al., 2005; Gopinath et al., 2012, Helzner et al., 2005; Lin et al., 2011, Tsimpida et al., 2020). Several epidemiological studies have shown salient demographic differences in the prevalence and incidence of audiometric hearing loss. For example, older individuals and males have higher prevalence and incidence of hearing loss (Cruickshanks et al., 1998, 2010). In terms of race, Black or African American individuals often have lower prevalence of audiometric hearing loss (Helzner et al., 2005). While self-reported hearing difficulty is related to audiometric hearing, they are not perfectly related (Nondahl et al., 1998; Sindusake et al., 2001). Therefore, it cannot be assumed that the changes over time to self-reported hearing difficulty follow the same trends as changes over time to audiometric hearing. Along these lines, it cannot be assumed that those changes would follow the same trends with demographic factors that are observed with audiometric hearing.
While some research conducted in samples of the general population has evaluated factors related to self-reported hearing loss or hearing difficulty assessed with a single question, (Curhan et al., 2019; Dillard et al., 2022), few studies of the general population have evaluated factors associated with a standard and comprehensive measure of self-reported hearing difficulty, such as the RHHI or HHIE/A, and the studies that have done so are cross-sectional (Matthews et al., 1990; Chang et al. 2009; Arnold et al., 2021; Dillard et al., 2024b). Taken together, these studies show that audiometric hearing is not a perfect predictor of self-reported hearing difficulty and indicate there may be some demographic differences in reporting of hearing difficulty (Matthews et al., 1990; Chang et al., 2009; Arnold et al., 2021; Dillard et al., 2024b). One study conducted in a large sample of adults aged 65 or older showed that in models including data on audiometric hearing, demographics, lifestyle factors, and self-reported health, only audiometric hearing, marital status, and self-reported health were associated with hearing handicap (Chang et al., 2009). Another study, conducted in the Hispanic Community Health Study/Study of Latinos, found that acculturation, sex, pure-tone average, and income were associated with a HHIE/A score > 8 points (Arnold et al., 2021). A recent cross-sectional study conducted in the same cohort as the present study showed that demographic factors, including age, sex, and race, audiometric hearing, and physical and mental health were associated with the presence of RHHI hearing difficulty, defined as a score ≥ 6 points (Dillard et al., 2024b).
However, to the authors’ knowledge, there are no studies that have evaluated changes in hearing difficulty over time and associated factors. Longitudinal data are needed to understand the change over time on measures of hearing difficulty and could also inform understanding of temporal relationships of change in hearing difficulty with some associated factors. In this study, we focus on relationships of longitudinal changes of self-reported hearing difficulty with demographic and hearing-related factors only. This allows for a comprehensive and exploratory evaluation of how hearing difficulty changes over time across different subgroups of interest.
Understanding how the RHHI changes longitudinally could inform the use of the RHHI, or similar tools, in clinical and research settings. Therefore, the purpose of this study was to describe how the RHHI changes over time in a community-based sample of the general population, and determine how these changes are influenced by age, sex, race, audiometric hearing, and hearing aid use.
MATERIALS AND METHODS
Study population
The Medical University of South Carolina (MUSC) Longitudinal Cohort Study of Age-related Hearing Loss is an ongoing (1988-current) community-based cohort study based in Charleston, SC. The cohort has been described in detail in past publications (Matthews et al., 1997; Lee et al., 2005; Dubno et al., 2008; Simpson et al., 2019). Participants are continuously enrolled into the cohort and are recruited from the community through advertisements and subject referral. They must be aged 18 years or older, and in good general health with no evidence of conductive hearing loss or active otologic or neurologic disease. All protocols for this study were approved by the Institutional Review Board at MUSC (Approval ID: E-607R) and data were collected under informed written consent.
The baseline examination consists of three to six visits that include comprehensive measures of hearing, and health and hearing-related history. The battery of tests includes pure-tone air conduction audiometry, speech recognition measures in quiet and noise, middle ear measurements, otoacoustic emissions, auditory brainstem responses, and surveys focused on demographics and general and hearing-related health, including the HHIE/A, from which the RHHI can be derived (Ventry & Weinstein, 1982; Newman et al., 1990; Cassarly et al., 2020).
Following the baseline examination, participants attend annual follow-up visits, during which pure-tone audiometric thresholds are collected and participants update their hearing and health history, including details on hearing aid uptake and use. Every 2 to 3 years after baseline, participants attend a comprehensive follow-up visit where most of the measures described above, including the HHIE/A, are repeated.
Currently, there are 1,776 participants with baseline data. To be included in this study that utilizes longitudinal data, participants were required to have RHHI data from at least two examinations that were at least 6 months apart. Participants were excluded if they reported hearing aid use at their baseline examination, for reasons described below.
RHHI
The HHIE/A was administered by paper and pencil prior to audiometric testing, reporting of hearing health history, and participants’ knowledge of hearing-related test results. Per the HHIE/A instructions, participants who use hearing aids are instructed to respond to the questionnaire to capture the way they hear without wearing hearing aids. Prior to 2015, participants aged 60 years or older and under 60 years were administered either the HHIE or HHIA, respectively (Ventry & Weinstein, 1982; Newman et al., 1990). In 2015, the study protocol was modified so that all participants, regardless of age, were administered a modified version of the HHIE/A that included all 28 items from both tools. The HHIE/A each consist of 25 questions (3 questions differ between tools).
As detailed in Cassarly et al. (2020), the RHHI was created using the 22 common items on the HHIE/A via psychometric analyses, including nonparametric item response theory (IRT) and Mokken Scale Analysis (MSA), which was used to guide decision making for manifest invariant item ordering (MIIO) and scale length reduction (Mokken, 1971, Molenaar, 1971). This approach resulted in an 18-item unidimensional scale of self-perceived hearing difficulty. RHHI scores were derived from the HHIE/A. Like the HHIE/A, response options for the RHHI are yes (4), sometimes (2) and no (0) and the total score is the sum of all responses, with higher scores indicating greater perceived hearing difficulties. Therefore, RHHI scores range from 0 to 72.
The change in RHHI scores was calculated as the most recent RHHI score minus the baseline RHHI score. To define a substantial amount of change, we used a distribution-based technique based on Cohen’s effect size, defined as the standard deviation (SD) of population change times 0.5 (Demeyer et al., 2016; Norman et al., 2003, 2004; Sedaghat et al., 2019). We calculated substantial amount of change using data from all participants with two or more RHHI scores, regardless of their baseline or current hearing aid use. Using this approach, the definition of substantial change was determined to be ±6 points. Therefore, a substantial increase or decrease in RHHI hearing difficulty was defined as an increase or decrease of 6 points between baseline and final examinations, respectively. We chose to categorize substantial change in RHHI score, as described above, to distinguish between participants who experience substantial increase and substantial decrease in RHHI scores, as we anticipated that different factors may be related with these two outcomes, separately. Similar approaches have been used to define substantial amounts of change and associated factors in epidemiological studies of the general population (Dillard et al., 2020).
Audiometric testing
Pure-tone thresholds at frequencies 0.25, 0.5, 1.0, 2.0, 3.0, 4.0, 6.0 and 8.0 kHz were measured with a clinical audiometer equipped with TDH-39 headphones (Telephonics Corporation, Farmingdale, NY, USA) in a sound-treated booth. All audiological equipment is calibrated annually to the appropriate ANSI standards by manufacturers’ representatives (ANSI, 2018). Thresholds were measured in 5-dB steps following American Speech-Language-Hearing Association (2005) standards.
A pure-tone average (PTA) was calculated from threshold values at frequencies 0.5, 1.0, 2.0 and 4.0 kHz for each ear. For descriptive purposes, PTA in the worse ear was used to classify degree of hearing loss severity as normal (≤ 25 dB HL), mild (> 25–40 dB HL), or moderate or greater (> 40 dB HL). The category of moderate or greater hearing loss severity included participants with moderate (PTA >40–55 dB HL), moderately severe (PTA >55–70dB HL), severe (PTA >70–90dB HL), and profound (PTA >90dB HL) hearing loss to ensure adequate sample sizes for presentation of results stratified to hearing loss severity. PTA in the worse ear captures unilateral and asymmetrical hearing losses, in addition to bilateral hearing acuity, and this definition is used in epidemiological studies of the general population (e.g., Cruickshanks et al., 1998; Cassarly et al., 2020). PTA in the worse ear was used as a continuous variable in regression models (described below). The change in PTA was calculated as the PTA from the most recent examination, subsequently referred to as the ‘final’ examination, minus the baseline PTA.
Hearing aid use
At each examination, participants reported whether they currently own hearing aids. If they are hearing aid owners, they report the year hearing aids were obtained, whether they consider themselves successful hearing aid users and whether they use hearing aids at least twice per week. Baseline hearing aid users were excluded from this study in order to capture baseline RHHI scores that were not influenced by hearing aid use.
In this study, hearing aid users were defined as participants who self-reported successful hearing aid use and/or hearing aid use twice per week at any point in the study. All other participants (except for baseline hearing aid users who were excluded) were classified as non-users.
Demographic factors and time in study
Participants reported age, sex assigned at birth (female/male), and race according to US Census Bureau classifications (White, Black or African American, Asian, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, or Other) (U.S. Census Bureau, 2022). Baseline age was categorized as < 50, 50–59, 60–69, 70–79 or 80+ years for some descriptive analyses, and baseline age was modeled as a continuous variable in logistic regression models. Race was categorized as White or racial Minority to ensure appropriate sample sizes for analyses.
Participants in this cohort are continuously enrolled and have different amounts of follow-up time. Therefore, we calculated a variable to measure participants’ time in the study, defined as the date of the most recent examination with RHHI data minus the date of the baseline examination. In regression models, time in the study is defined as the number of months in the study. For descriptive purposes, time in the study is presented as number of years.
Statistical methods
All statistical analyses were conducted in SAS version 9.4 software (Cary, NC). For all analyses, statistical significance was defined by an alpha level of p < 0.05. Descriptive statistics were conducted to describe the study population, including their demographic characteristics and baseline and final RHHI scores. We used chi-square tests for categorical variables and one-way analysis of variance for continuous variables to determine differences by baseline age, sex, race, and baseline worse ear PTA for participants that were included and excluded from this study, and to determine differences between hearing aid users and non-users. Most of the analyses described below are presented for the entire study sample, then for non-users and hearing aid users, separately, given evidence of effect modification of hearing aid use. We evaluated effect modification using stratified models (VanderWeele, 2009; Corraini et al., 2017).
For descriptive purposes, we plot relationships of RHHI change with time in the study and PTA change with time in the study, for hearing aid users and non-users, separately, and together. For these relationships, we present regression coefficients (representing the slope of the regression lines) with corresponding 95% confidence intervals (CI). We also present differences in the regression coefficients for hearing aid users versus non-users, which were determined by the significance of the interaction terms of hearing aid use and time in the study in those models.
We estimated mean baseline and final RHHI scores and RHHI change over time, which are presented with corresponding 95% CI. The mean baseline scores are the arithmetic mean. Estimates for the final RHHI scores and RHHI change over time were generated from least squares means estimates from generalized linear regression models and were adjusted for time in the study (in months). Unadjusted mean values (baseline RHHI scores) and adjusted least squares means estimates (final RHHI scores and RHHI change over time), are presented for the entire sample, by hearing aid users and non-users, and for subgroups of baseline age group, sex, race, and baseline PTA group. These analyses are descriptive and focus on overall trends. We do not present differences (in terms of their significance) between or among subgroups.
Next, separate logistic regression models were used to evaluate the factors associated with substantial increase (+6 points) and decrease (−6 points) in self-reported hearing difficulty over time, in the entire study sample and stratified to non-users and hearing aid users. First, we built base models adjusted for time in the study (in months). Next, we built multivariable logistic regression models additionally adjusted for baseline age, sex, race, baseline worse ear PTA, and hearing aid use (in the entire study sample only). Results from logistic regression models are presented as odds ratios (OR) with corresponding 95% CI.
A sensitivity analysis included change in PTA in the multivariable-adjusted logistic regression models, to determine if PTA change was associated with substantial increase or decrease in RHHI self-reported hearing difficulty over time. Change in PTA was not included in the primary models (described above) because it was highly correlated with time in the study.
RESULTS
Of the 1776 participants with baseline data, 583 met the inclusion criteria described above and were included in this study. Participants included in this study sample, as compared to the 1193 who were not, were more likely to be older at baseline (p<0.01) and White race (p<0.01) but did not differ by sex (p=0.51) or baseline PTA (p=0.19).
Entire sample
Baseline characteristics, and baseline and final RHHI scores and change
The baseline characteristics of the 583 participants included in this study are in Table 1. Participants’ mean age was 66.4 (SD 9.1) years, 59.9% were female, and 14.2% were Minority race (13.7% of the sample was Black or African American). Participants’ mean baseline PTA was 24.9 (SD 13.1) dB HL, and the mean amount of PTA change was 7.0 (SD 7.4) dB. The mean baseline and final RHHI scores were 7.9 (SD 10.6) and 9.2 (SD 11.8) points, respectively, and the mean change was 1.3 (SD 9.2) points.
Table 1:
Baseline study sample characteristics
| Entire sample (n=583)† |
Non-users (n=460) |
Hearing aid users (n=121) |
|||||
|---|---|---|---|---|---|---|---|
|
| |||||||
| Characteristic | Mean or n | SD or % | Mean or n | SD or % | Mean or n | SD or % | p-value |
|
| |||||||
| Age (years) | 66.4 | 9.1 | 65.7 | 9.7 | 69.0 | 5.6 | <0.01 |
| < 50 | 28 | 4.8% | 28 | 6.1% | 0 | -- | |
| 50–59 | 54 | 9.3% | 47 | 10.2% | 7 | 5.8% | |
| 60–69 | 288 | 49.4% | 225 | 48.9% | 62 | 51.2% | |
| 70–79 | 194 | 33.3% | 114 | 31.3% | 49 | 40.5% | |
| 80+ | 19 | 3.3% | 16 | 3.5% | 3 | 2.5% | |
|
| |||||||
| Female | 349 | 59.9% | 292 | 63.5% | 56 | 46.3% | <0.01 |
|
| |||||||
| Minority race | 83 | 14.2% | 80 | 17.4% | 3 | 2.5% | <0.01 |
|
| |||||||
| Baseline PTA (dB HL) | 24.9 | 13.1 | 21.7 | 11.6 | 37.0 | 11.3 | <0.01 |
| Normal | 323 | 55.4% | 306 | 66.5% | 17 | 14.0% | |
| Mild | 177 | 13.4% | 123 | 26.7% | 53 | 43.8% | |
| Moderate or greater | 83 | 14.2% | 31 | 6.7% | 51 | 42.2% | |
|
| |||||||
| PTA Change (dB) | 7.0 | 7.4 | 5.8 | 6.7 | 11.4 | 8.1 | <0.01 |
|
| |||||||
| Number of examinations | 3.2 | 1.4 | 3.1 | 1.3 | 3.7 | 1.6 | <0.01 |
| 2 | 252 | 43.2% | 215 | 46.7% | 36 | 29.8% | |
| 3 | 137 | 23.5% | 111 | 24.1% | 26 | 21.5% | |
| 4 | 89 | 15.3% | 68 | 14.8% | 21 | 17.4% | |
| 5 | 56 | 9.6% | 35 | 7.6% | 20 | 16.5% | |
| 6+ | 49 | 8.4% | 31 | 6.7% | 18 | 14.9% | |
|
| |||||||
| Time in study (years) | 7.6 | 4.9 | 7.1 | 4.7 | 9.4 | 5.3 | <0.01 |
|
| |||||||
| Baseline RHHI | 7.9 | 10.6 | 6.0 | 8.9 | 14.6 | 12.3 | <0.01 |
|
| |||||||
| Final RHHI | 9.2 | 11.8 | 6.6 | 9.4 | 18.8 | 14.6 | <0.01 |
|
| |||||||
| RHHI Change | 1.3 | 9.2 | 0.6 | 7.3 | 4.2 | 13.8 | <0.01 |
Two participants had missing data for hearing aid use so were excluded from analyses stratified to hearing aid use.
Note: PTA defined as average of thresholds at 0.5, 1.0, 2.0, and 4.0 kHz in the worse ear. Normal (PTA ≤ 25 dB HL), mild (PTA > 25–40 dB HL), moderate or greater (PTA > 40 dB HL).
Hearing aid users (vs non-users) were more likely to be older (p<0.01), male (p<0.01), White race (<0.01), have higher (worse) baseline PTA (p<0.01) and more PTA change (p<0.01), more examinations (p<0.01) and have more years in the study (p<0.01). Furthermore, hearing aid users (vs non-users) had higher baseline (<0.01) and final RHHI scores (p<0.01) and more RHHI change (p<0.01) (Table 1).
Substantial RHHI change over time
Most participants (n=381; 65.4%) did not experience substantial change in hearing difficulty between baseline and final examination, whereas 125 (21.4%) experienced substantial increase and 77 (13.2%) experienced substantial decrease in hearing difficulty. Results from logistic regression models evaluating factors associated with substantial increase and decrease in hearing difficulty over time are in Table 2. In separate base models adjusted for time in the study, older baseline age (per +1 year; OR: 1.03, 95% CI: 1.00, 1.06), higher baseline PTA (per +1 dB; OR: 1.05, 95% CI: 1.04, 1.07), and hearing aid use (OR: 4.16, 95% CI: 2.59, 6.66) were associated with higher odds of substantial increase in hearing difficulty. In a multivariable model, baseline PTA (per +1 dB; OR: 1.04, 95% CI: 1.02, 1.06) and hearing aid use (OR: 2.47, 95% CI: 1.44, 4.24) remained associated with substantial increase in hearing difficulty; time in the study (OR: 1.01, 95% CI: 1.00, 1.01) was also associated with substantial increase in hearing difficulty (Table 2).
Table 2:
Results from base and multivariable logistic regression models evaluating factors associated with substantial increase and decrease in hearing difficulty in the entire study sample.
| Substantial increase in hearing difficulty | Substantial decrease in hearing difficulty | |||
|---|---|---|---|---|
| Characteristic | Base OR (95% CI) | Multivariable OR (95% CI) | Base OR (95% CI) | Multivariable OR (95% CI) |
| Age (per +1 year) | 1.03 (1.00, 1.06) | 1.00 (0.97, 1.03) | 1.02 (0.99, 1.05) | 0.99 (0.96, 1.03) |
| Female sex | 0.83 (0.55, 1.25) | 1.20 (0.76, 1.91) | 0.48 (0.30, 0.79) | 0.69 (0.40, 1.18) |
| Minority race | 0.56 (0.28, 1.11) | 0.88 (0.42, 1.82) | 0.59 (0.27, 1.29) | 0.91 (0.40, 2.10) |
| PTA (per +1 dB) | 1.05 (1.04, 1.07) | 1.04 (1.02, 1.06) | 1.05 (1.03, 1.07) | 1.04 (1.02, 1.07) |
| Hearing aid use | 4.16 (2.59, 6.66) | 2.47 (1.44, 4.24) | 2.63 (1.47, 4.70) | 1.15 (0.57, 2.35) |
| Time in study (per +1 month)† | 1.01 (1.00, 1.01) | 1.01 (1.00, 1.01) | 1.00 (0.998, 1.01) | 1.00 (1.00, 1.01) |
Time in study is unadjusted in base models.
Note: Results are presented as odds ratios (OR) with corresponding 95% confidence intervals (95% CI). The referent group is participants with no RHHI change. Base models were adjusted for time in study.
Separate base logistic regression models showed female sex was associated with lower odds of substantial decrease in hearing difficulty (OR: 0.48, 95% CI: 0.30, 0.79), whereas higher baseline PTA (per +1 dB; OR: 1.05, 95% CI: 1.03, 1.07) and hearing aid use (OR: 2.63, 95% CI: 1.47, 4.70) were associated with higher odds. In a multivariable model, only baseline PTA (per +1 dB; OR: 1.04, 95% CI: 1.02, 1.07) remained associated with substantial decrease in hearing difficulty, and time in the study (OR: 1.00, 95% CI: 1.00, 1.01) was also associated with substantial decrease in hearing difficulty (Table 2).
Next, we describe RHHI change and report associated demographic and hearing-related factors in i) non-users, and ii) hearing aid users, separately. Relationships of RHHI change with time in the study are in Figure 1. In non-users, RHHI change increases slightly with more years in the study (regression coefficient: 0.15 [95% CI: 0.01, 0.30]; Figure 1, Panel 1). In contrast, in hearing aid users, RHHI change increases more precipitously with more years in the study, and relationships show more variability (regression coefficient: 0.57 [95% CI: 0.10, 1.04]; Figure 1, Panel 2). RHHI scores for hearing aid users, compared to non-users, increase significantly more with more years in the study (p=0.02).
Figure 1:
Relationships of RHHI change with time in the study in non-users, hearing aid users, and overall.
Figure 2 shows relationships of PTA change with time in the study. Like for RHHI change, PTA change increases with more years in the study. The average slope of PTA change by years in the study is similar (p=0.97) for non-users (regression coefficient: 0.94 [95% CI: 0.84, 1.04]; Figure 2, Panel 1) and hearing aid users (regression coefficient: 0.94 [95% CI: 0.72, 1.16]; Figure 2, Panel 2).
Figure 2:
Relationships of PTA change with time in the study in non-users, hearing aid users, and overall.
Figure 2 Note: PTA defined as average of thresholds at 0.5, 1.0, 2.0, and 4.0 kHz in the worse ear.
RHHI change in non-users
Baseline and final RHHI scores and change
There were 460 participants who did not use hearing aids (Table 1). The mean baseline and final RHHI scores for non-users were 6.0 (SD 8.9) and 6.6 (SD 9.4), respectively, and the mean RHHI change was 0.6 (SD 7.3).
The mean baseline and final RHHI scores, and RHHI change over time, stratified to baseline age group, for non-users are in Figure 3 (left panel). The estimates plotted in Figure 3 suggest that the amount of change was highest in younger (<50 years) and older (70–89, 80+ years) age groups. Across most age groups, the amount of change was positive, indicating more hearing difficulty; however, in participants aged 60–69 years, the mean change was slightly negative, indicating overall less hearing difficulty.
Figure 3:
Mean (95% confidence interval or standard deviation) baseline and final RHHI scores and RHHI change, stratified by baseline age group, in non-users and hearing aid users.
Figure 3 Note: There are no hearing aid users aged <50 years. Estimates for final RHHI and RHHI change are adjusted for the time in study (months). RHHI change estimates may not be exactly equal to final minus baseline RHHI scores because baseline scores are not adjusted for time in study. Years in the study are presented for descriptive purposes. The numbers of participants in each group are presented in Table 1.
Table 3 displays mean sex- and race-stratified RHHI scores and change in non-users. As compared to males, females had lower baseline and final RHHI scores and more RHHI change. In terms of race, White participants (vs Minority) had higher baseline and final RHHI scores and more RHHI change.
Table 3:
Mean baseline and final RHHI scores and RHHI change in non-users, stratified to sex and race, and hearing aid users, stratified to sex.
| Non-users | Hearing aid users | |||||
|---|---|---|---|---|---|---|
| Sex | Race | Sex | ||||
| Female (n=292) | Male (n=168) | White (n=380) | Minority (n=80) | Female (n=56) | Male (n=65) | |
| Baseline RHHI | 5.1 (4.1, 6.1) | 7.5 (6.2, 8.8) | 6.4 (5.5, 7.3) | 4.0 (2.0, 5.6) | 12.5 (9.3, 15.7) | 16.4 (13.4, 19.4) |
| Final RHHI | 6.0 (4.9, 7.1) | 7.6 (6.1, 8.9) | 7.2 (6.2, 8.1) | 3.9 (1.8, 6.0) | 17.9 (14.0, 12.7) | 19.6 (16.0, 23.2) |
| RHHI Change | 1.0 (0.1, 1.8) | 0.04 (−1.1, 1.1) | 0.7 (−0.04, 1.4) | 0.3 (−1.3, 1.9) | 5.3 (1.7, 8.9) | 3.3 (−0.1, 6.6) |
| Time in study (years) | 7.1 (4.6) | 7.3 (4.9) | 7.5 (4.9) | 5.4 (2.9) | 9.8 (5.0) | 9.0 (5.5) |
Note. Results are presented as mean (95% CI or SD). Estimates for final RHHI and RHHI change are adjusted for the time in study. RHHI change estimates may not be exactly equal to final minus baseline RHHI scores because baseline scores are not adjusted for time in study. Years in the study are presented for descriptive purposes. Estimates stratified by race for hearing aid users are not presented due to low sample size of Minority hearing aid users.
Figure 4 (left panel) displays mean RHHI scores and change, stratified to degree of hearing loss, for non-users. Baseline and final RHHI scores, and change, were higher with greater degrees of hearing loss.
Figure 4:
Mean (95% confidence interval or standard deviation) baseline and final RHHI scores and RHHI change, stratified by degree of hearing loss, in non-users and hearing aid users.
Figure 4 Note: Estimates for final RHHI and RHHI change are adjusted for the time in study (months). RHHI change estimates may not be exactly equal to final minus baseline RHHI scores because baseline scores are not adjusted for time in study. Years in the study are presented for descriptive purposes. Normal (PTA ≤ 25 dB HL), Mild (26–40 dB HL), Moderate or greater (P TA > 40 dB HL). The numbers of participants in each group are presented in Table 1.
Substantial RHHI change over time
The distribution of RHHI change over time for non-users is in Figure 5 (left panel). Most non-users (n=331; 72.0%) did not experience substantial RHHI change. Seventy-four (16.1%) non-users experienced a substantial increase, whereas 55 (12.0%) experienced a substantial decrease in hearing difficulty.
Figure 5:
Distribution of RHHI change in non-users and hearing aid users.
Results from models evaluating factors associated with substantial increase and decrease in hearing difficulty are in Table 4. In separate base models, baseline PTA was associated with higher odds of substantial increase in hearing difficulty (per +1 dB; 1.06, 95% CI: 1.04, 1.09). After multivariable adjustment, baseline PTA (per +1 dB; OR: 1.07, 95% CI: 1.04, 1.10) remained associated with higher odds of substantial increase in hearing difficulty, and time in the study (per +1 month; OR: 1.01; 95% CI: 1.00, 1.01) was also associated with substantial increase in hearing difficulty.
Table 4:
Results from base and multivariable logistic regression models evaluating factors associated with substantial increase and decrease in hearing difficulty in non-users.
| Substantial increase in hearing difficulty | Substantial decrease in hearing difficulty | |||
|---|---|---|---|---|
| Characteristic | Base OR (95% CI) | Multivariable OR (95% CI) | Base OR (95% CI) | Multivariable OR (95% CI) |
| Age (per +1 year) | 1.02 (0.99, 1.05) | 0.99 (0.96, 1.02) | 1.02 (0.99, 1.06) | 1.00 (0.96, 1.04) |
| Female sex | 1.07 (0.63, 1.82) | 1.54 (0.86, 2.75) | 0.56 (0.31, 0.99) | 0.71 (0.39, 1.32) |
| Minority race | 0.61 (0.28, 1.29) | 0.75 (0.34, 1.69) | 0.59 (0.25, 1.37) | 0.78 (0.32, 1.87) |
| PTA (per +1 dB) | 1.06 (1.04, 1.09) | 1.07 (1.04, 1.10) | 1.04 (1.02, 1.07) | 1.04 (1.01, 1.07) |
| Time in study (per +1 month)† | 1.00 (0.998 1.01) | 1.01 (1.00, 1.01) | 1.00 (0.99, 1.004) | 1.00 (0.99, 1.01) |
Time in study is unadjusted in base models.
Note. Results are presented as odds ratios (OR) with corresponding 95% confidence intervals (95% CI). The referent group is participants with no RHHI change. Base models were adjusted for time in study.
In separate base models, female sex (OR: 0.56, 95% CI 0.31, 0.99) and baseline PTA (per +1 dB; OR: 1.04, 95% CI: 1.02, 1.07) were associated with higher odds of substantial decrease in hearing difficulty. After multivariable adjustment, only baseline PTA remained associated with higher odds of substantial decrease in hearing difficulty (per +1 dB; OR: 1.04, 95% CI: 1.01, 1.07) (Table 4).
RHHI change in hearing aid users
Baseline and final RHHI scores and change
There were 121 hearing aid users, and their mean baseline and final RHHI scores were 14.6 (SD 12.3) and 18.8 (SD 14.6), respectively, and their mean RHHI change was 4.2 (SD 13.8) (Table 1).
In terms of baseline age, baseline and final RHHI scores were highest among 50- to 59-year-olds, and on average, they showed decreased hearing difficulty (Figure 3, right panel). All other age groups showed increased hearing difficulty (Figure 3, right panel). As compared to non-users, hearing aid users showed higher baseline and final RHHI scores and more change, and estimates show more variability (Figure 3).
Table 3 shows RHHI scores and change, stratified by sex, for hearing aid users. Like the trends observed among non-users, females (vs males) had lower baseline and final RHHI scores and more RHHI change.
In terms of degree of hearing loss (Figure 4, right panel), baseline and final RHHI scores increased with increasing degrees of baseline hearing loss in hearing aid users. The amount of RHHI change decreased with increasing degrees of baseline hearing loss (Figure 4, right panel).
Substantial RHHI change over time
As shown in Figure 5 (right panel), 50 (41.3%) hearing aid users did not experience substantial RHHI change over time, whereas 51 (42.2%) experienced substantial increase, and 20 (16.5%) experienced substantial decrease in hearing difficulty. As compared to non-users, a higher proportion of hearing aid users experienced both substantial increase and decrease in hearing difficulty.
In separate base logistic regression models in hearing aid users, none of the investigated factors were associated with substantial increase in RHHI hearing difficulty, except time in the study (per +1 month; OR: 1.01; 95% CI: 1.00, 1.02; Table 5). In the multivariable model, only time in the study was associated with substantial increase in RHHI hearing difficulty (per +1 month; OR: 1.01; 95% CI: 1.00, 1.02; Table 5). In base logistic regression models in hearing aid users, baseline PTA was associated with higher odds of substantial decrease in RHHI hearing difficulty (per +1 dB; OR: 1.05, 95% CI: 1.00, 1.10). An association with baseline PTA did not remain after multivariable adjustment, and only time in the study was associated with substantial decrease in hearing difficulty (per +1 month; OR: 1.01; 95% CI: 1.00, 1.02; Table 5).
Table 5:
Results from base and multivariable models evaluating factors associated with substantial increase and decrease in hearing difficulty in hearing aid users.
| Substantial increase in hearing difficulty | Substantial decrease in hearing difficulty | |||
|---|---|---|---|---|
| Characteristic | Base OR (95% CI) | Multivariable OR (95% CI) | Base OR (95% CI) | Multivariable OR (95% CI) |
| Age (per +1 year) | 0.99 (0.91, 1.07) | 1.01 (0.92, 1.10) | 0.98 (0.90, 1.07) | 0.98 (0.89, 1.08) |
| Female sex | 0.76 (0.34, 1.71) | 0.61 (0.25, 1.46) | 0.34 (0.11, 1.08) | 0.46 (0.13, 1.60) |
| PTA (per +1 dB) | 0.97 (0.93, 1.01) | 0.96 (0.92, 1.01) | 1.05 (1.00, 1.10) | 1.04 (0.99, 1.10) |
| Time in study (per +1 month)† | 1.01 (1.00, 1.02) | 1.01 (1.00, 1.02) | 1.00 (0.996, 1.01) | 1.01 (1.00, 1.02) |
Time in study is unadjusted in base models.
Note. Results are presented as odds ratios (OR) with corresponding 95% confidence intervals (95% CI). The referent group is participants with no RHHI change. Base models were adjusted for time in study. Race was not included in models given low sample size of Minority hearing aid users.
Sensitivity analyses
Including PTA change in multivariable-adjusted models of substantial RHHI increase or decrease in the entire sample, and for hearing aid users and non-users separately, did not change the overall trends in the results presented above (data not shown).
DISCUSSION
This study, conducted in a community-based sample of the general population and with a mean of 7.6 years of follow-up time, described how RHHI scores change over time and determined factors associated with change. Key findings from this study are that the mean amount of RHHI change was relatively small in the entire sample, which included both hearing aid users and non-users, and that hearing aid use and baseline hearing thresholds (PTA) appear to be key factors that contribute to RHHI change over time. To the authors’ knowledge, this is the first study to describe change to a standard measure of self-reported hearing difficulty, such as the RHHI or HHIE/A, over time in a sample of the general population. Results from this study can inform clinicians and researchers about the expected amount of change on the RHHI and associated demographic and hearing-related factors.
On average, participants experienced more RHHI hearing difficulty over time. However, as stated above, the average amount of change was relatively small (1.3 points) in the entire sample and was considerably different for non-users (0.6 points) and hearing aid users (4.2 points). Importantly, these averages align with the relatively small amount of PTA change in the entire sample (7.0 dB) and among non-users (5.8 dB) and hearing aid users (11.4 dB). In part, the finding that hearing difficulty increased over time could be attributed to aging and the concomitant worsening of audiometric hearing over time, which would likely be consistent with increased self-reported hearing difficulty. The main results presented in this study did not account for increased age or changes to PTA over time, however, results were adjusted for time in the study, which is correlated with changes to age and PTA and therefore partially accounts for those factors. While a sensitivity analysis that adjusted for PTA change over time did not meaningfully change the results, importantly, it was not possible to disentangle overlapping relationships of time in the study, changes to age and PTA given the high correlations of these factors. Therefore, it is possible that time in the study, and changes in age and PTA all contribute to changes to RHHI scores over time.
Nearly two-thirds of participants in this sample did not report a substantial change (±6 points) in RHHI hearing difficulty. It is possible that a mean of 7.6 years of follow-up was not enough time to observe substantial changes to RHHI hearing difficulty. Another potential explanation for these findings is that participants were administered the RHHI several times, which may increase the likelihood that they would answer questions similarly across follow-up examinations given they are familiar with the task. Furthermore, it is possible that, over time, participants have learned to cope with their hearing loss, which may tend to stabilize RHHI scores even with gradual increases in hearing thresholds with increasing age (Gomez & Madley, 2001). Given the paucity of longitudinal studies that have evaluated changes to measures of self-reported hearing difficulty in samples of the general population, it is not possible to directly compare results related to the amount of RHHI change with other studies. Similarly, this was the first study (to our knowledge) to define a value for substantial change in RHHI hearing difficulty (±6 points). Future research is needed, including validation in clinical cohorts, to determine if this definition of substantial change could be identified as a ‘clinically meaningful’ change in RHHI score.
One goal of this study was to describe how the RHHI changes over time in a sample of the general population, and therefore we did not focus on evaluating changes to RHHI scores before and after hearing aid uptake. Other research has consistently reported that the use of hearing aids reduces hearing difficulties or handicap (Mulrow et al., 1992; Dawes et al., 2015). In this study, findings indicate that hearing aid users showed considerably more change, on average, to hearing difficulty over time, even after adjustment for demographic and hearing-related factors, and that most hearing aid users experienced substantial change (either increase or decrease) in RHHI hearing difficulty. These results contrast with those for non-users, who, on average, experienced less RHHI change, and most did not experience substantial change in RHHI hearing difficulty. Importantly, results from this study showed there was considerable variability in changes to perceived hearing difficulty among hearing aid users. In part, this variability could be influenced by the relatively low number of hearing aid users in this sample. Another possible explanation for this finding is that while participants are instructed to answer RHHI questions based on their experiences without their hearing aids, it may be difficult for hearing aid users to do so. For example, if hearing aid users are utilizing their hearing aids consistently, it may be difficult for them to report their hearing difficulty without their hearing aids in the situations evaluated by the RHHI. Furthermore, this study did not consider the type of hearing aid(s) used or the quality of the hearing aid fitting, both of which may contribute to the variability in hearing aid users’ outcomes, such as self-reported hearing difficulty.
Baseline PTA was associated with both substantial increase and decrease in RHHI hearing difficulty in the entire sample and among non-users, but not among hearing aid users. In general, in descriptive analyses stratified to hearing loss severity, the amount of RHHI change increased with greater (worse) degrees of hearing loss among non-users, and the opposite trend was observed in hearing aid users, that is, the amount of RHHI change generally decreased with higher levels of hearing loss. These findings suggest that among non-users, but not hearing aid users, baseline PTA may be a main predictor of RHHI change. The opposite trends with baseline PTA between hearing aid users and non-users could be attributed to the finding that hearing aid users have higher baseline PTA and experience more PTA change than non-users. Hearing aid users with lesser degrees of baseline hearing loss (normal, mild) have more room for their PTA to increase, which would lead to a corresponding increase in RHHI self-reported hearing difficulty. Conversely, those with moderate or greater hearing loss at baseline are closer to the limits of hearing, and therefore experience less increase in PTA, which would correspond to more stable RHHI scores.
Demographic factors, including age, sex, and race, were not associated with substantial increase or decrease on the RHHI in multivariable models. However, some interesting patterns emerge from descriptive analyses stratified to those factors. For example, among non-users, younger (<50 years) and older (80+ years) age groups showed slightly more RHHI change than other age groups, although those groups also showed the most variability, which may be due to limited sample sizes in those groups. Among hearing aid users, participants aged 50–59 years showed improved RHHI scores, on average, whereas estimates of RHHI change were relatively stable for hearing aid users aged 60–69, 70–79, and 80+ years. This may be because older individuals may benefit from hearing aids less than younger individuals, given that hearing aids do not restore sensory input, nor do they improve audibility when cochlear cells are severely degenerated (Moore, 2001). Another possible explanation is that older individuals likely had hearing loss for longer periods of time and may have learned to cope with their hearing loss. In this study, females showed slightly more RHHI change than males. Furthermore, in non-users, White participants showed slightly more RHHI change than Minority participants, but it was not possible to evaluate racial differences in RHHI change among hearing aid users given the small number of Minority hearing aid users in this sample. These results are consistent with some studies that have shown demographic differences in self-reported hearing difficulty (Chang et al., 2009; Choi et al., 2016), as well as other self-reported measures of health (Boerma et al., 2016).
In a cross-sectional study conducted in this cohort, older age, and Minority (vs White) race were associated with decreased odds of RHHI self-reported hearing difficulty, whereas female (vs male) sex and higher PTA were associated with lower odds of RHHI self-reported hearing difficulty, defined as an RHHI score ≥ 6 points, in a single model (Dillard et al., 2024b). In the present study, neither age, sex, nor race was associated with substantial RHHI increase or decrease after multivariable adjustment. Other cohort studies have shown inconsistent cross-sectional associations of HHIE/A scores with age and sex (Chang et al., 2009, Arnold et al., 2021), but have not evaluated associations with race. The finding that baseline PTA was associated with substantial RHHI increase and decrease is consistent with cross-sectional analyses conducted in this, and other cohorts (Chang et al., 2009; Arnold et al., 2021; Dillard et al., 2024b). It is possible that more follow-up time is needed to determine additional factors associated with RHHI change. Furthermore, there may be other factors, beyond demographics and audiometric hearing, that influence RHHI change.
Understanding the amount of RHHI change and associated factors in a sample of the general population is important for research and clinical practice. First, study results can inform the interpretation of research that uses the RHHI in longitudinal samples. Clinically, the RHHI is used as a patient-reported outcome measure, and therefore, study results can inform clinicians about the expected amount of RHHI change over time. Future research should determine if other factors, in addition to demographic and hearing-related factors, are associated with RHHI change over time. Furthermore, results from this study should be validated in other cohorts.
Strengths of this community-based cohort study include its large and diverse sample that contains comprehensive measures of hearing. This cohort study is similar to other epidemiological studies of age-related hearing loss in terms of age and audiometric hearing (Gates et al., 1990; Cruickshanks et al., 1998; Dubno et al., 2008), which enhances the generalizability of study findings. However, some limitations exist. While this study has strengths related to its generalizability, study participants live in a relatively small geographic region, and approximately half of participants were classified as having high socioeconomic position, both of which limit the generalizability of study results. Most Minority participants in this study were Black or African American, so relationships related to RHHI change could not be comprehensively evaluated in other races. There were few hearing aid users who were Minority race, so it was not possible to evaluate racial differences in RHHI change among hearing aid users. Along these lines, Minority participants had less time in the study, on average, which could bias their estimates of RHHI change to be lower. However, estimates of RHHI change were adjusted for the time in the study, which would reduce the risk of bias from differences in time in the study by race. This study does not report results from statistical tests comparing baseline or final RHHI scores, or RHHI change by baseline age group, sex, race, or baseline PTA. Those results must be interpreted as capturing overall trends in the data.
CONCLUSIONS
This study described how RHHI scores change over time and determined associated factors. The amount of RHHI change was relatively small. Hearing aid use showed a strong association with substantial increase in RHHI hearing difficulty. Higher PTA was associated with increased and decreased RHHI hearing difficulty in hearing aid users but not non-users. Results from this study can help to inform clinicians and researchers about the expected amount of change on the RHHI and associated demographic and hearing-related factors.
FUNDING
This work was funded (in part) by the National Institutes of Health/National Institute on Deafness and Other Communication Disorders Individual Postdoctoral Fellowship (F32 DC021078), Institutional Training Grant (T32 DC014435) and Clinical Research Center (P50 DC 000422) awarded to the Medical University of South Carolina and by the South Carolina Clinical and Translational Research (SCTR) Institute, with an academic home at the Medical University of South Carolina, NIH/NCATS Grant number UL1 TR001450. This investigation was conducted in a facility constructed with support from Research Facilities Improvement Program Grant Number C06 RR14516 from the NIH/NCRR.
Footnotes
Conflicts of interest: Authors have no conflicts of interest to disclose.
DATA AVAILABILITY STATEMENT
The datasets generated and/or analysed during the current study are not publicly available but data are available from the corresponding author on reasonable request and with a data use agreement and institutional approvals according to guidelines of the Medical University of South Carolina.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analysed during the current study are not publicly available but data are available from the corresponding author on reasonable request and with a data use agreement and institutional approvals according to guidelines of the Medical University of South Carolina.