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RESEARCH ARTICLE |
a Departments of Family Medicine, Charles R. Drew University of Medicine & Science, Los Angeles, California
b Departments of Ophthalmology, Charles R. Drew University of Medicine & Science, Los Angeles, California
c Departments of Psychiatry, Charles R. Drew University of Medicine & Science, Los Angeles, California
d Jules Stein Eye Institute, University of California, Los Angeles
e Department of Psychiatry, University of California, Los Angeles
Mohsen Bazargan, Department of Family Medicine, Charles R. Drew University of Medicine & Science, 1725 East 120th Street, MP#30, Los Angeles, CA 90059 E-mail: mobazarg{at}cdrewu.edu.
Decision Editor: Toni C. Antonucci, PhD
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Abstract |
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 TOP Abstract Vision ImpairmentHearing ImpairmentVision and Hearing ImpairmentsVision and Hearing Impairments...ObjectivesMethodsResultsDiscussionReferences |
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QUALITY of life and subjective well-being and their determinants have received considerable attention in recent decades, particularly in gerontological research. Connections between subjective well-being and functional independence have been solidly established (Thomae 1992
). Consequently, one major goal of aging research is understanding how to maintain the functional independence of elderly individuals. Sensory declines represent a broad category of age-related changes that can lead to diminished quality of life and loss of independence (National Institutes of Health [NIH] Guide, 1999). Previous studies have lacked systematically collected data addressing the consequences of sensory impairment and the relationship between sensory impairment and factors other than age and gender. The limited number of studies concerning the prevalence of hearing loss and vision impairment and their causes—and the lack of strategies to prevent, detect, and treat the deleterious effects of hearing loss and vision impairment—point to a significant gap in the knowledge base concerning elderly persons in general and aged minority populations in particular.
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Vision Impairment |
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TOPAbstractVision ImpairmentHearing ImpairmentVision and Hearing ImpairmentsVision and Hearing Impairments...ObjectivesMethodsResultsDiscussionReferences |
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). Prevalence rates of blindness and visual impairment for elderly persons have been consistently demonstrated to increase sharply and monotonically with increasing age (Dana et al. 1990; Klein, Klein, Linton, and De Mets 1991; Salive et al. 1992; Tielsch, Sommer, Witt, Katz, and Royall 1990). It is estimated that as many as 2.7 million older people in the United States currently experience severe vision impairment. Given the projected growth of the elderly population, the number of elderly people with severe vision impairment will increase to 6 million by the year 2030 (Horowitz 1995).
A national sample of a representative population of Americans aged 50 years or older documented that self-reports of "trouble seeing" (even with glasses or contacts) were found in 20% of the middle-aged and aged population (Kington, Rogowski, Lillard, and Lee 1997). Similarly, a separate recent national sample of United States community-dwelling persons age 70 or older documented that 27% of participants rated their vision as fair or poor (Lee, Smith, and Kington 1999). Using the 1994 National Health Interview Survey (NHIS) core, the NHIS disability supplement, and the 1994 NHIS Second Supplement on Aging, Campbell, Crews, Moriarty, Zack, and Blackman 1999 reported that vision impairment—defined as blindness in one eye, blindness in both eyes, or any other trouble seeing—has been reported by 18.1% of adults age 70 or older.
Multiple psychosocial factors have been associated with poor vision in elderly people. Visual impairment among elderly people has been correlated with psychological distress, low morale, and depression (Bazargan and Hamm-Baugh 1995; Branch, Horowitz, and Carr 1989; Horowitz 1995); reduced self-worth, diminished emotional security, and quality of life and well-being (Brenner, Curbow, Javitt, Legro, and Sommer 1993; Lee, Spritzer, and Hays 1997; Scott, Smiddy, Schiffman, Feuer, and Pappas 1999; Wahl, Schilling, Oswald, and Heyl 1999); functional status (Branch et al. 1989; Kington et al. 1997; Lee et al. 1997, Lee et al. 1999; Salive et al. 1992; Scott et al. 1999; West et al. 1997); and social interaction and engagement (Resnick, Fries, and Verbrugge 1997).
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Hearing Impairment |
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TOPAbstractVision ImpairmentHearing ImpairmentVision and Hearing ImpairmentsVision and Hearing Impairments...ObjectivesMethodsResultsDiscussionReferences |
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). Recent studies have shown that hearing impairment among elderly people has doubled in prevalence over the past 30 years in the United States, based on self-reported data on trouble hearing (Strawbridge, Wallhagen, Shema, and Kaplan 2000). Hearing loss affects more than 4 million Americans age 65 and older (National Academy on an Aging Society 1999). A recent survey conducted in Alameda County in California showed that over 21% of those age 60 and older reported that moderate or severe hearing impairment affected their understanding of words in a normal conversation, hearing words clearly over the telephone, and hearing well enough to carry on a conversation in a noisy room (Strawbridge et al. 2000). Similarly, another recent national sample of a representative population of Americans age 70 or older showed that 25% of the respondents rated their hearing as fair or poor (Lee et al. 1999).
Yet it is important to note that self-reported hearing underestimates hearing impairment among aged populations. Nondahl and colleagues 1998 documented a 14.8% and 42.7% variation between objective measures and measures of self-reported hearing impairment. Another study showed that elderly people tend to wait approximately 10 years from the onset of hearing loss before seeking help (Weinstein 1989). Abutan, Hoes, Van Dalsen, Verschuure, and Prins 1993 screened a sample of participants age 60 and older for hearing impairment and found that only 64.4% of those with hearing impairment reported hearing complaints (Abutan et al. 1993). Several researchers argued that this reflects the popular belief among older adults that hearing loss is a normal part of aging and not a health problem that deserves special attention (Nondahl et al. 1998).
Reviewing the current data, Tesch-Romer 1997 reported that at least 30% of those older than age 65 are so severely hearing impaired that they would benefit from a hearing aid. However, several studies have documented that a large proportion of the elderly population with hearing problems are not diagnosed or treated (Abutan et al. 1993; Sangster, Gerace, and Seewald 1991; Trumble and Piterman 1992; Wilson, Fleming, and Donaldson 1993).
Hearing impairments in elderly people have been associated with a variety of mental conditions, including depression (Cacciatore et al. 1999; Carabellese et al. 1993; Maggi et al. 1998; Strawbridge et al. 2000), self-reported memory problems (Bazargan and Barbe 1994), cognitive capacity (Cacciatore et al. 1999; Lindenberger and Baltes 1994; Marsiske, Delius, Lindenberger, Scherer, and Tesch-Romer 1996), and suspiciousness and paranoid ideation (Almeida, Howard, Levy, and David 1995; Bazargan, Bazargan, and King 2001). In addition, several studies in older adults have indicated a significant relationship between hearing impairment and self-sufficiency (Carabellese et al. 1993), communication ability (Garstecki 1987; Lichtenstein, Bess, and Logan 1988; Pedersen and Rosenhall 1991), quality of life and well-being (Mulrow et al. 1990; Scherer and Frisina 1998), social integration (Resnick et al. 1997), and social isolation (Strawbridge et al. 2000; Weinstein and Ventry 1982).
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Vision and Hearing Impairments |
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TOPAbstractVision ImpairmentHearing ImpairmentVision and Hearing ImpairmentsVision and Hearing Impairments...ObjectivesMethodsResultsDiscussionReferences |
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). Given the well-documented negative impact of hearing and vision loss on mental and physical health and the dramatic consequences with regard to physical and social functioning, it is surprising that only a handful of researchers included both hearing and vision impairment in assessment of quality of life in old age. Although age-related changes in single sensory systems have been investigated in geriatric populations using both epidemiological and psychophysical approaches, only a few studies have addressed interaction or commonalities among sensory systems (NIH Guide 1999). Wahl and Tesch-Romer 2000 argued that age-related losses in both the visual and auditory systems negatively affect different strata of communication and social functioning. They provided evidence that although vision loss has a strong influence on one's interaction with the physical and spatial environment, hearing loss has a strong impact on the surface structure of social functioning in day-to-day interactions. Therefore, one should expect interaction effects between hearing and vision impairment on quality of life. The combined impact of hearing and vision loss is likely to be more detrimental to the well-being of individuals than either single impairment.
Few studies have examined the combined effect of hearing and vision impairment on subsequent disability and mortality (Reuben, Mui, Damesyn, Moore, and Greendale 1999). The National Institute on Aging in collaboration with several other agencies from the National Institutes of Health are currently inviting grant applications in the area of age-related changes in multiple sensory systems. In particular, it is encouraging studies on the effects of multiple sensory deficits on functional status and quality of life in the elderly population (NIH Guide 1999).
Using the first National Health and Nutrition Examination Survey and its first Epidemiologic Follow-Up Study, Reuben and colleagues 1999 examined the relationship between vision and hearing loss and 10-year mortality and functional dependence in community-dwelling older adults. They documented that, in this population-based longitudinal study, vision, hearing, and combined sensory impairment were predictive of functional dependency at 10 years even after adjusting for sociodemographic characteristics and several chronic conditions. They reported that those who had combined sensory impairment had the highest risk of subsequent functional impairment. In another longitudinal study of the relationship of vision and hearing impairment to 1-year functional decline, LaForge, Spector, and Sternberg 1992 reported that although hearing impairment alone may not be an important risk factor for decline in daily activities, there appears to be an additive effect when hearing impairment is considered in combination with vision impairment. They documented an approximately 40% greater risk of functional decline for persons with both vision and hearing impairments over persons with impairment in vision only. However, other recent research examining the prognostic value of sensory impairment in older persons did not examine the interaction effects of hearing and vision impairment on functional status (Dargent-Molina, Hays, and Breart 1996; Lee et al. 1999; Rudberg, Furner, Dunn, and Cassel 1993).
Empirical evidence that documents the full sequence of events involving the indirect effects of sensory impairment on quality of life and well-being is lacking. Only one previous study (Lee et al. 1999) has examined the impact of both vision and hearing impairment on psychological well-being. Piecing together findings on strong associations between sensory impairment and functional status (as well as associations between functional status and depression, social isolation, and the potential impact of these intermediate outcomes on quality of life and well-being), it is evident that comprehensive data are lacking and that there is an urgent need for additional research. A better understanding of these challenges could enable more effective interventions for people with declining vision and hearing (Guralnik 1999).
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Vision and Hearing Impairments Among Aged African Americans |
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TOPAbstractVision ImpairmentHearing ImpairmentVision and Hearing ImpairmentsVision and Hearing Impairments...ObjectivesMethodsResultsDiscussionReferences |
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documented a relationship between hearing handicap and overall rating of mental health as well as with key aspects of psychological function including lethargy, life satisfaction, and paranoia. Also documented among aged African Americans is the significant negative impact of hearing impairment on paranoid ideation symptoms (Bazargan et al. 2001).
The Salisbury Eye Evaluation project shows that African American persons had almost twice the rate of visual impairment of White persons (Munoz et al. 2000; West et al. 1997). This study documented that African Americans had a disproportionate number of blinding diseases, particularly those amenable to eye care intervention (Munoz et al. 2000). Similarly, a recent population-based survey conducted in east Baltimore demonstrated significantly higher rates of visual impairment for African Americans compared with Whites for virtually every age group (Sommer et al. 1991; Tielsch et al. 1991). Age-adjusted estimates showed African Americans to be 80% more likely to be visually impaired and more than twice as likely to be blind than Whites. It is estimated that glaucoma-related blindness is six to eight times more common among African Americans than Whites (Javitt et al. 1991). The Select Committee on Aging 1985 identified visually impaired elderly persons as an underserved population. Elderly minority persons with late-life vision and hearing loss, in particular, are doubly at risk and are unlikely to be sufficiently accommodated within the existing structure of care providers.
Despite substantial evidence that elderly African Americans experience significantly increased ocular morbidity and visual impairment compared with their White counterparts, there is almost no research on psychosocial correlates of vision impairment among this segment of the population (Baker, March, and Scott 1998). In addition, there is little research on vision and hearing impairment that treats elderly African American individuals as a separate group for study purposes (Bazargan, Baker, and Bazargan 1998). Specifically, no studies exist of the effects of multiple sensory deficits on functional status and quality of life in aged African Americans.
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Objectives |
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TOPAbstractVision ImpairmentHearing ImpairmentVision and Hearing ImpairmentsVision and Hearing Impairments...ObjectivesMethodsResultsDiscussionReferences |
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The issue of subjective well-being has a long history in the field of adult development and aging (Chatters and Jackson 1989). Subjective well-being is important as a psychological summary of the quality of an individual's life in society. Several social psychological concepts tap aspects of quality of life indirectly, such as self-esteem, depression, anxiety, and alienation, but only subjective well-being and happiness have a "bottom-line" finality in terms of consequences for individuals (Andrews and Robinson 1991).
Using multivariate analysis, this study isolates the independent impact of vision and hearing impairment as well as the combined effects of these characteristics on psychological well-being, while controlling for the effects of other confounding variables. In addition to self-rated vision and hearing, the following variables were selected as the potential correlates of psychological well-being: demographic data, socioeconomic status, social support, religious participation, stressful life events, cognitive status, limitation of daily activities, and health status. The rationale for the inclusion of these variables is based on previous research on psychological well-being among elderly populations (Brown, Green, Milburn, and Milburn 1992; Chambre 1984; Chatters 1988; Coke 1992; Jackson, Herzog, and Chatters 1980; Lawton 1986; Lee et al. 1999; McIntosh and Danigelis 1995). By evaluating and documenting the impact of vision and hearing on mental health and psychological well-being, the study will yield knowledge that will contribute to the enhancement of the quality of life among elderly African American persons.
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Methods |
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TOPAbstractVision ImpairmentHearing ImpairmentVision and Hearing ImpairmentsVision and Hearing Impairments...ObjectivesMethodsResultsDiscussionReferences |
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Characteristics of the Sample
The mean age of the sample was 72.4 years; the range was 62 to 99 years. The majority of the sample participants were female (76%). Only 21% of the sample were currently married; 54.5% were widowed; and 24.6% were divorced, separated, or never married. The mean level of education was 8.7 years, with almost 48.9% of the participants indicating that they had no formal education beyond eighth grade. Approximately 25% of the sample had completed high school. Seventy percent of the sample had a monthly income of $750 or less ($9,000 per year). The average income was $680 per month ($8,160 per year).
Census information supports the representativeness of our sample. The 1990 census (U.S. Bureau of the Census 1990) indicated that 61% of the total population of elderly African Americans in New Orleans, age 62 years or older, were female. In data that are also reflected in our sample, the census showed that among the elderly African American population, 51% completed less than a ninth-grade education and only 24% completed high school or had post–high school education. Sixty-one percent of the elderly African Americans in New Orleans had a yearly income of $9,999 or less (U.S. Bureau of the Census 1990).
Only 8.4% of the sample rated their present health status as excellent. Thirty-two percent described their health as good, and 41.8% and 17.6% rated their health as fair and poor, respectively. Reports from the Centers for Disease Control and Prevention (National Center for Health Statistics 1995) have supported our data; they indicated that 9.3% and 17.6% of African Americans age 65 and older who participated in a 1992 NHIS reported their health status as excellent and poor, respectively. In all, 7.4% reported no chronic illness. The most frequently cited chronic illnesses were arthritis (65.8%), hypertension (61.7%), eye problems (46.7%), heart trouble (33.1%), diabetes (23.7%), and circulation problems (23.5%).
Measures
Table 1 displays the means, standard deviations, coding algorithms, and psychometric properties of the variables used in this study.
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). To enhance the sensitivity and precision of this instrument, following Koenig, Kvale, and Ferrel 1988, the possible responses for each item were expanded from the original binary response categories of yes or no to a 4-point scale, with responses ranging from strongly agree to strongly disagree. The total score ranged from 17 to 68, and Cronbach's alpha for this version of the PGC Morale Scale was .872. Higher scores in this index represent a higher level of psychological well-being.
Demographics.
There were four measures of demographic characteristics: age, sex, education, and financial strain. Gender was coded dichotomously; male was coded 1 and female was coded 0. Education and age were measured in actual number of years. Financial strain was measured on the basis of the question "Is having enough money to live on 1 = a very serious problem, 2 = a somewhat serious problem, or 3 = hardly a problem at all for you personally?"
Religious participation and volunteer activity.
Religious participation was measured in response to the question "On the average, how often have you attended religious services (on Sunday morning, evening, and/or other days) during the past 2 years?" The response categories ranged from 1 = nearly every day to 5 = less than once a year. Volunteer work was coded dichotomously, with volunteers coded 1, and no volunteer work coded 0.
Social support.
Social support was measured with a modified version of the Inventory of Social Supportive Behaviors (Barrera, Sandler, and Ramsay 1981; Krause 1986). This measure of emotional support consisted of 11 items and was based on the personal qualities or behavior of a support person, including empathy, caring, love, and trust. A higher score on this indicator reflects greater emotional support. The reliability of this 11-item composite scale was .87.
Stressful life events.
Stressful life events were measured in this study using a revised version of the scale developed by Holmes and Rahe 1967, which consisted of 16 items. The items used for this index include stressful life events such as death of a spouse, death of a child, and being the victim of a crime. A higher score on the scale indicated a greater number of stressful life events.
Cognitive deficit.
Cognitive impairment was measured with the Mini-Mental State Examination (MMSE; Folstein, Folstein, and McHugh 1975). The MMSE has been extensively tested for its ability to accurately identify cognitive impairment (Tombaugh, McIntyre, and McIntyre 1992). However, a few studies have shown that the educational level and ethnicity of the participants influenced the results of the MMSE (Escobar et al. 1986; Murden, McRae, Kaner, and Bucknam 1991). The MMSE used in this study consisted of five cognitive domains or functions: orientation to time, orientation to place, registration of three words, attention (spelling world backward), and recall of three words. Following Morris, Mohs, Rogers, Fillenbaum, and Heyman 1988, this study did not include the calculation function (the serial 7s) but used world as an alternative. The word world was spelled forward (or corrected) before spelling it backward. In addition, language and visual construction domains that had been identified to be influenced by education, ethnicity, and language (Escobar et al. 1986: Murden et al. 1991) were not used. This 18-item scale ranged from 0 to 21 (instead of from 0 to 30 in original scale), and a lower score indicates higher deficit. The mean and standard deviation were 17.0 and 2.44, respectively.
Functional limitation.
The extent of limitation in respondents' daily activities was derived from 13 questions asking whether any given chronic illness (i.e., heart disease, hypertension, diabetes, arthritis, respiratory diseases, kidney, teeth and gums, ear, eye, blood circulation problems, stroke, and cancer) limited their daily activities. The response categories ranged from 3 = a great deal to 0 = not at all. The total score ranged from 0 to 39; higher scores indicated increased limitation in daily activities.
Self-reported health status.
Three items were used to construct an index to measure self-reported health status. The items were (a) self-reported health rating, (b) self-reported health status compared with 2 years ago, and (c) self-reported health status compared with peers of the same age. The total score ranged from 1 to 10, and Cronbach's alpha for this unweighted summated scale was .67. Lower scores in this index represent a higher level of perceived health status.
Self-reported vision and hearing impairment.
Self-reported vision was evaluated with the question "How is your vision [if respondent wears glasses] after you put your glasses on?" with response categories of 1 = excellent, 2 = good, 3 = fair, and 4 = poor. Similarly, self-reported hearing was evaluated by means of a single question asking participants "How is your hearing?" with response categories of 1 = excellent, 2 = good, 3 = fair, and 4 = poor.
Statistical Analysis
In addition to examination of bivariate relationships, we used the general linear model (GLM) with one dependent variable (psychological well-being) to examine the relationship between vision and hearing and subjective well-being. The GLM univariate procedure provides regression analysis and analysis of variance for the dependent variable by one or more factors and/or variables (SPSS Advanced Models 9.0; SPSS, Inc 1999). Using this GLM procedure, we examined the effects of vision and hearing on the means of subjective well-being for different levels of hearing and vision, respectively (with all other variables held constant). Post hoc multiple comparison tests were performed. In addition, we examined the possible indirect relationship between vision and hearing problems and well-being using a hierarchical regression approach. After performing multiple regression analysis, standardized regression coefficients (betas) for all independent variables were documented.
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Results |
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TOPAbstractVision ImpairmentHearing ImpairmentVision and Hearing ImpairmentsVision and Hearing Impairments...ObjectivesMethodsResultsDiscussionReferences |
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2 (3, N = 998) = 12.89, p < .05.
Almost 13.9% of this sample reported excellent hearing, and over 60% described their hearing as good. However, 16.8% and 9.3% reported fair or poor hearing, respectively (Table 1 ). Only 3.1% of our sample wore hearing aids. Furthermore, only 4 out of 92 (4.3%) individuals who described their hearing as poor were using hearing aids. One hundred forty-two participants (14.2%) described both their vision and hearing as either fair or poor. A significant relationship between self-reported vision and hearing was detected, 2 (9, N = 998) = 120, p < .0001.
Bivariate Relationship
Analysis of the bivariate relationship between the psychological well-being index and each of the selected independent variables indicated that all variables except age were significantly related to psychological well-being among our sample of elderly African American persons (Table 2 ). Specifically, both self-rated hearing and vision showed a significant relationship with the psychological well-being index, indicating that at the bivariate level, a lower level of psychological well-being was associated with a lower rating of vision (r = -.31, p < .0001) and hearing (r = -.18, p < .0001).
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The strong bivariate relationship between vision impairment and psychological well-being (r = -.31; Table 2 ) was significantly reduced in the multiple regression analysis (ß = -0.11). Using a hierarchical regression approach, the possible mediating roles of different independent variables were tested. Our analysis shows that the strong bivariate association between vision impairment and well-being was reduced as a result of the variance shared by the two variables limitation in daily activities and self-rated health status. Examination of data indicates that those individuals who reported more vision impairment were also more likely to report a higher number of limitations in their daily activities and a lower level of self-rated health status, the combined effects of which led to a lower level of psychological well-being. Similarly, the statistically significant bivariate relationship between hearing and psychological well-being (r = -.18; Table 2 ) was eliminated in the multiple regression analysis. Using a hierarchical regression approach, our data show that hearing impairment lost its significance due to the variance shared by these same variables, limitation of daily activities and self-rated health status. Therefore, in addition to the direct impact of vision on psychological well-being, vision also indirectly affected well-being through limitation of daily activity and self-rated health status, whereas hearing impairment showed only indirect impact on well-being mediated mostly by functional status.
Finally, in testing for the presence of interaction effects among vision and hearing, a new model was formed. This model included all independent variables and one product term (Vision x Hearing). To avoid multicollinearity between the predictor variables (first-order terms) and the product term, the independent variables were centered (i.e., placed in deviation score form so their means were zero) and the product term was formed by multiplying together the centered independent variables (Aiken and West 1991). No interaction effect was detected.
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Discussion |
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TOPAbstractVision ImpairmentHearing ImpairmentVision and Hearing ImpairmentsVision and Hearing Impairments...ObjectivesMethodsResultsDiscussionReferences |
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This study reports a high prevalence of self-reported vision and hearing impairment among a representative sample of elderly African Americans compared with prevalence rates previously reported for the general aged American (i.e., predominantly White) population. More than 36.5% of our sample described their vision as either fair (21.4%) or poor (15.1%). Twenty-six percent (26%) of this sample reported fair (16.8%) or poor (9.3%) hearing. In addition, 14.2% of our sample described both their vision and hearing as either fair or poor. By contrast, despite using instruments identical to those used in this study to assess self-rated vision and hearing impairment, the longitudinal study of United States community-dwelling persons age 70 or older (with 86% White) reported that 27% of respondents rated their vision as fair (18%) or poor (9%) and 25% rated their hearing as fair (19%) or poor (6%; Lee et al. 1999). The longitudinal study sample was older than the sample surveyed in our study and would therefore be expected to manifest higher rather than lower rates of impairment relative to those reported for this investigation. Using other instruments to measure self-reported hearing and vision impairment, a national sample of elderly people age 65 and older (with 86.6% White) reported 15.9% vision and 14.2% hearing impairment, respectively, and 4.1% with both hearing and vision impairment (Reuben et al. 1999). These data would appear to support a significantly greater burden of vision and hearing impairment among elderly African Americans compared with other Americans.
An interesting finding in this study is the large discrepancy between the use of vision aids and hearing aids among our sample of elderly African Americans. Over 84% of the persons in the sample reported using eyeglasses. By contrast, only 3.1% of this sample reported using a hearing aid. More remarkable is the fact that only 4.3% of those reporting poor hearing were using hearing aids. The prevalence of appropriate eyeglass use is undoubtedly inflated secondary to the fact that over-the-counter reading glasses were not distinguished from glasses prescribed by an eyecare professional. However, even if this inflation factor is taken into account, differences between the rate of use of ocular and auditory prostheses would remain substantial.
To the best of our knowledge, no information about prevalence of hearing aid use among aged African Americans has been published. However, other studies have documented a low rate of hearing aid use among the elderly population. Reviewing the literature on prevalence of hearing aid use among older adults with hearing loss, Popelka and colleagues 1998 reported that 10% to 21% of people with hearing loss used amplification. Therefore, the results of our study suggest a lower level of hearing aid use among elderly African Americans compared with the general elderly population (4% vs 10%–21%). This underutilization of hearing aids reflects the general pattern of health care utilization among this segment of the population (Bazargan et al. 1998). Findings of some empirical studies have documented the existence of substantial unmet medical needs among African Americans (Blendon, Aike, Freeman, and Corey 1989), and others have indicated that elderly African Americans tend to underuse services that could enhance their health status and quality of life (Mui and Burnette 1994).
There are two general obstacles to the purchase of hearing aids by elderly persons, both of them related to cost. First, most insurance plans do not have hearing aid coverage; second, Medicare does not cover hearing aids (National Academy on an Aging Society 1999). The National Council on the Aging commissioned a survey of 2,300 people age 50 and older with hearing impairments to examine barriers to wearing hearing aids. When asked to cite the reason or reasons why they do not wear hearing aids, about one half of the respondents cited the cost (The National Council on the Aging 1999).
Another common reason that elderly people do not use amplification devices relates to a lack of knowledge and the stigma of wearing hearing aids (National Academy on an Aging Society 1999). Hearing aid acceptance improves when the patient is motivated and counseled regarding the device's function and realistic expectations (Garstecki and Erler 1998). Programs are needed to educate elderly patients, their families, and their primary care physicians as to the potential benefits available through the use of an appropriate amplification system (Wolf and Hewitt 1999). There are limited educational materials about hearing loss available to elderly minority people (Wolf and Hewitt 1999). Lavizzo-Mourey, Smith, Sims, and Taylor 1994 developed an informational booklet about hearing impairment and its consequences and offered a free hearing screening. The pamphlets were distributed to 14,000 households with elderly African American and Latino members residing in the Philadelphia area. Of those who responded (fewer than 3%), 75% failed the initial hearing screening; 58% of those who presented for follow-up were found to have significant hearing loss. Lavizzo-Mourey and colleagues 1994 argued that hearing loss appears to be common and untreated among inner-city minority elderly populations. Innovative, culturally sensitive interventions are urgently needed to reduce hearing impairment among this segment of the population (Lavizzo-Mourey et al. 1994). Providing information, referrals, and resources to patients and alerting general practitioners regarding the opportunity to influence hearing impairment are several strategies that can begin to address improvement in hearing conditions.
Analysis of the bivariate relationship between the psychological well-being index and each of the selected independent variables indicates that all variables except age are significantly related to psychological well-being among our sample of elderly African American persons. Specifically, both self-rated hearing and vision showed significant relationships with the psychological well-being index, indicating that at the bivariate level, a lower level of psychological well-being was associated with a poorer rating of vision and hearing.
Multivariate analysis of our sample suggests that the risk of having a lower level of psychological well-being was greater for persons with visual impairments, even after other related variables including functional limitation, perceived health status, and cognition were held constant. In addition, the multiple regression analysis indicates that the self-reported health index, functional limitation, stressful life events, financial strain, religious participation and religiosity, and cognitive deficit are all related to psychological well-being in the expected direction. However, multivariate analysis detected no significant direct relationship between hearing and subjective well-being. The bivariate relationship between hearing impairment and psychological well-being was weakened to a nonsignificant level in the multiple regression analysis due to the variance shared by limitation in daily activities and self-rated health status.
Our results are consistent with those reported in previous investigations. Examining the relationship of self-rated vision and hearing to functional status and well-being among a large sample of seniors age 70 and older, Lee and colleagues 1999 reported that visual and hearing impairment appear to have a significant relationship to overall functioning in the oldest old, regardless of income. Another study by Dargent-Molinia and colleagues (1996) among a sample of community-dwelling women age 75 and older showed that severe sensory impairments are strongly related to physical dependency in older women. They documented that 11.3% and 6.9% of their sample reported serious visual and hearing difficulty, respectively. Similarly, LaForge and colleagues 1992 examined the data from baseline and 1-year follow-up of the study of the well-being of older people in Cleveland, Ohio. They reported that vision impairments and, to a lesser extent, hearing impairments were found to be significant risk factors for functional decline. However, Rudberg and colleagues 1993 used the baseline 1984 and the 1988 reinterviews from the longitudinal study of aging, a nationally representative survey of noninstitutionalized persons 70 years of age and older, and reported that although visual impairment by itself is an independent risk factor for future activity of daily living disability, hearing impairment was not independently related to increased activity of daily living disability.
Although we documented no significant independent association between hearing impairment and subjective well-being, it is important to note that using hierarchical regression models we explicitly documented that the impact of hearing impairment on subjective well-being is primarily mediated through functional status. Therefore, we conclude that hearing loss in older African Americans can influence subjective well-being through its effect on functional status. More important, this investigation has identified hearing impairment as a mutable determinant of functional status and well-being, suggesting the importance of a renewed emphasis on audiological rehabilitation for this population. Consistent with our findings, Cacciatore and colleagues 1999 documented a strong association between hearing impairment and depression and cognitive deficit among a sample of aged Italians. They suggested that hearing aids may protect against cognitive impairment and disability, improving quality of life for aged people. In agreement with Cacciatore and colleagues' results, other studies have documented a significant reduction of psychotic activity and improvement in mood, self-sufficiency in instrumental activities of daily living, and social relationships after the fitting of hearing-aids (Almeida 1993; Appollonio, Carabellese, Frattola, and Trabucchi 1996; Eastwood, Corbin, and Reed 1981; Khan, Clark, and Oyebode 1988; Kreeger, Raulin, Grace, and Priest 1995). Moreover, a recent longitudinal study has documented an indirect impact of hearing deficit on mortality mediated by psychosocial parameters among a sample of noninstitutionalized elderly persons (Appollonio, Carabellese, Magni, Frattola, and Trabucchi 1995).
One of the limitations of our investigation is the cross-sectional nature of the study. This study design does not allow the determination of the direction of causality between self-reported vision and hearing impairments and psychological well-being. However, there is evidence to support the argument that vision and hearing impairments are legitimate predictors of psychological well-being. Burack-Weiss 1995 argued that it is important to understand how the individual elder perceives vision loss. Loss of sensory and motor abilities contributes to a sense of vulnerability, dependence on others, and fear of additional loss. Some elderly persons feel helpless and hopeless. A decrease in mobility may precipitate social withdrawal and isolation. It is not unusual, Burack-Weiss reported, to hear a visually impaired older person say something such as "I could handle the pain of arthritis. I even got to the point that I could inject the insulin. But now that my sight is fading, I don't know how I can go on" (p. 29).
The use of self-report in the assessment of vision and hearing status raises several issues related to the interpretation of our results. First, it is notable that previous studies have demonstrated relatively low sensitivity and high specificity for self-reported hearing and vision impairment compared with objective measures (Hiller and Krueger 1983; Nondahl et al. 1998; Rubenstein and Lohr 1983; Stone and Shannon 1978). Sensitivity of self-reported hearing and vision impairments compared with objective measures is less than 70%. The methodologic consequence of low sensitivity is misclassification of participants according to vision and hearing status. The expected statistical consequences of the misclassification of visual and hearing status would be to bias our results by underestimating the magnitude of the relationship between vision and hearing and other variables, including psychological well-being (Klein, Klein, Moss, and DeMets 1986). More important, given that our study used a single item for measuring vision and hearing impairment, it is notable that a single-item measure, which provides a very narrow assessment, was still significantly related to other study variables. Perhaps even stronger relationships would have been detected if subjective hearing and vision were assessed with a broader index. Future research should include more comprehensive scales tapping sensory impairment.
Second, the validity of self-report in the assessment of vision and hearing status should not be evaluated exclusively in terms of its agreement with objective measurements. Numerous studies have demonstrated that subjective assessment of vision has intrinsic value because it often manifests dimensions of visual function and dysfunction, which are inadequately captured by standard objective measures such as visual acuity (Brenner et al. 1993). Whether or not the subjective evaluation of vision and hearing impairment corresponds to objective reality, the subjective beliefs that people hold about the situations in which they find themselves are powerful forces that have real consequences in their daily lives (Cutler and Grams 1988).
In summary, our data indicate a high prevalence of self-reported vision and self-reported hearing impairment in a large representative sample of aged African Americans. In addition, these data document a statistically significant independent association between vision impairment and psychological well-being even after controlling for sociodemographic characteristics, stressful life events, health-related factors, and functional status. By contrast, the association between hearing impairment and psychological well-being was found to be important but weaker than that observed for vision impairment and primarily mediated through its effect on functional status. The very low rate of hearing aid use even among those individuals reporting poor hearing suggests the potential for significant impact on the psychological well-being of African American elderly people through increased emphasis on and accessibility to audiological rehabilitation through the use of hearing aids.
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Acknowledgments |
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We are grateful to Lindsay Berg and Risa Flynn for their professional editorial assistance and helpful comments and suggestions, which were crucial in developing this article.
Received for publication January 5, 2000. Accepted for publication August 10, 2000.
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TOPAbstractVision ImpairmentHearing ImpairmentVision and Hearing ImpairmentsVision and Hearing Impairments...ObjectivesMethodsResultsDiscussionReferences |
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