Integrated care for older people (ICOPE) Guidelines on community-level interventions to manage declines in intrinsic capacity

Evidence profile: hearing loss

Scoping question: Does case finding and provision of hearing aids or assistive listening devices produce any benefit or harm for older people 60 years of age and over with hearing loss?

The full ICOPE guidelines and complete set of evidence profiles are available at who.int/ageing/publications/guidelines-icope

Painting: “Wet in Wet” by Gusta van der Meer. At 75 years of age, Gusta has an artistic style that is fresh, distinctive and vibrant. A long-time lover of art, she finds that dementia is no barrier to her artistic expression. Appreciated not just for her art but also for the support and encouragement she gives to other artists with dementia, Gusta participates in a weekly art class. Copyright by Gusta van der Meer. All rights reserved Evidence profile: hearing loss

Contents

Background ...... 1 Part 1: Evidence review ...... 2 Scoping question in PICO format (population, intervention, comparison, outcome) ...... 2 Search strategy ...... 3 List of systematic reviews and individual studies identified by the search process ...... 3 PICO Table ...... 4 Narrative description of the studies that went were included into in the analysis ...... 5 GRADE table 1: Screening for hearing loss versus no screening ...... 7 GRADE table 2: Screening and provision of hearing aids ...... 8 GRADE table 3: Self-management support compared with control (alternative interventions) ...... 10 Part 2: From evidence to recommendations ...... 12 Summary of evidence ...... 12 Evidence-to-recommendations table ...... 13 Guideline development group recommendation and remarks ...... 17 References ...... 18 Annex 1: Search strategy (MEDLINE and Embase 2015) ...... 19 Annex 2: PRISMA flow diagram for hearing screening and referral ...... 20

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ICOPE guidelines – World Health Organization 1 Evidence profile: hearing loss

Background

With increasing age, deterioration in hearing sensitivity rises sharply. background noise, for example) and behavioural adaptations for the About one third of people 65 years of age and over live with some person and for their communication partners (simple degree of hearing loss (1) and between 50% and 80% of older communication techniques such as speaking clearly, for people over 80 years of age experience significant hearing loss. example) (6). Research evidence suggests that hearing aid use is Hearing loss in older people is strongly associated with reduced strongly associated with improved communication in relationships, functional ability, social isolation, depression, cognitive decline, emotional stability, perception of mental functioning and physical poor quality of life, and need for care (2-5). In most countries, health, and improved quality of life (8). Despite the increased particularly in low- and middle-income countries, hearing loss in availability of technology, however, the proportion of older people older people is largely undetected and undertreated. This is mainly with hearing loss who use hearing aids is low (9). Moreover, due to the lack of community outreach and lack of systematic evidence on effective case-finding and provision of care is mostly screening for hearing loss in older people. from high-income countries. The extent to which this evidence is generalizable to poorly resourced settings is unclear. This review The most common form of treatment for hearing loss in older has thus set out to answer two key questions: first, whether people is the provision of a hearing aid. Effective management screening and provision of hearing aids are effective in improving strategies for hearing loss includes use of technologies such as hearing-related outcomes; and, second, whether education and hearing aids, assistive listening devices or cochlear implants, health educational interventions improve the uptake or adherence of education, environmental modifications (reducing interfering hearing aid use among older people.

ICOPE guidelines – World Health Organization 2 Evidence profile: hearing loss

Part 1: Evidence review

Scoping question in PICO format (population, intervention, comparison, outcome)

Population • Older people 60 years of age and over (both male and female) with hearing loss

Intervention • Screening and provision of a hearing aid or assistive listening device • Educational intervention to improve uptake or use of hearing aid

Comparison • Referral, no service or delayed treatment

Outcome • Critical: Improvement in communication, social function, hearing use • Important: Depression, quality of life, use of verbal communication strategy, self-reported hearing handicap scale

ICOPE guidelines – World Health Organization 3 Evidence profile: hearing loss

Search strategy — Mulrow CD, Aguilar C, Endicott JE, Tuley MR, Velez R, Charlip WS, et al. Quality-of-life changes and hearing impairment: a Details of the search strategy are given in Annex 1. randomized trial. Ann Intern Med. 1990;113(3):188–94. doi:10.7326/0003-4819-113-3-188. List of systematic reviews and individual studies — Yueh B, Collins MP, Souza PE, Boyko EJ, Loovis CF, Heagerty identified by the search process PJ, Liu C-F, Hedrick SC. Long-term effectiveness of screening for hearing loss: the screening for auditory impairment-which hearing Included in GRADE tables (10–13) assessment test (SAI-WHAT) randomized trial. J Am Geriatr Soc.

2010;58(3):427–34. doi:10.1111/j.1532-5415.2010.02738.x. — Barker F, Mackenzie E, Elliott L, Jones S, de Lusignan S.

Interventions to improve hearing aid use in adult auditory — Yueh B, Souza PE, McDowell JA, Collins MP, Loovis CF, rehabilitation. Cochrane Database Sys Rev. 2014(7):CD010342. Hedrick SC, et al. Randomized trial of amplification strategies. Arch doi:10.1002/14651858.CD010342.pub2. Otolaryngol Head Neck Surg. 2001;127(10):1197–204.

doi:10.1001/archotol.127.10.1197.

______

3 GRADE: Grading of Recommendations Assessment, Development and Evaluation. More information: http://gradeworkinggroup.org

ICOPE guidelines – World Health Organization 4 Evidence profile: hearing loss

PICO Table

Intervention/ Systematic reviews and individual studies Outcomes Explanation comparison used for GRADE tables

1 Screening for hearing loss • Use of hearing aid Yueh B, Collins MP, Souza PE, Boyko EJ, Loovis Individual study compared with no screening • Improvement in Aural CF, Heagerty PJ, Liu C-F, Hedrick SC. Long-term relevant to the Rehabilitation scale effectiveness of screening for hearing loss: the area screening for auditory impairment-which hearing assessment test (SAI-WHAT) randomized trial. J Am Geriatr Soc. 2010;58(3):427–34. doi:10.1111/j.1532-5415.2010.02738.x. (10)

2 Screening and provision of • Social function Yueh B, Souza PE, McDowell JA, Collins MP, Individual study hearing aid or assistive • Communication Loovis CF, Hedrick SC, et al. Randomized trial of relevant to the listening device compared • Depression amplification strategies. Arch Otolaryngol Head area with no hearing aid or Neck Surg. 2001;127(10):1197–204.

assistive listening device doi:10.1001/archotol.127.10.1197. (11)

Mulrow CD, Aguilar C, Endicott JE, Tuley MR, Velez R, Charlip WS, et al. Quality-of-life changes Individual study and hearing impairment: a randomized trial. Ann relevant to the Intern Med. 1990;113(3):188–94. area doi:10.7326/0003-4819-113-3-188. (12)

3 Self-management support • Quality of life Barker F, Mackenzie E, Elliott L, Jones S, de Systematic compared with control • Self-reported hearing Lusignan S. Interventions to improve hearing aid review relevant to (alternative intervention) handicap use in adult auditory rehabilitation. Cochrane the area • Use of verbal Database Sys Rev. 2014(7):CD010342. communication strategy doi:10.1002/14651858.CD010342.pub2. (13)

ICOPE guidelines – World Health Organization 5 Evidence profile: hearing loss

Narrative description of the studies that went were programmable-directional digital hearing aid (intervention group), included into in the analysis while ineligible veterans were randomly assigned to an assistive listening device or no treatment. The main outcome measures were Screening for hearing loss versus no screening (GRADE table 1) hearing-related quality of life, self-rated communication ability, adherence to use, and willingness to pay for the amplification The larger of the two studies by Yueh et al. (10) was a randomized devices (measured three months after fitting). controlled trial on screening for hearing loss. It compared three different screening strategies (the AudioScope, based on inability to Self-management support interventions compared with controls hear a 40dB tone at 2000 Hz in either ear; the Hearing Handicap (GRADE table 3) Inventory for Elderly-Screening (HHIE-S), based on a score >10; or the AudioScope plus the HHIE-S versus usual care (no screening) The Cochrane systematic review by Barker et al. (13) assessed the in 2305 older veterans (94% males). The primary outcome of the effectiveness of interventions to promote the use of hearing aids in study was hearing aid use at one year. adults with acquired hearing loss fitted with at least one hearing aid. The search for trials was conducted using the Cochrane Ear, Nose Screening and provision of hearing aids (GRADE table 2) and Throat Disorders Group trial register and additional sources for both published and unpublished data. There were no language or Two trials evaluated the benefits of amplification compared with no date restrictions on the search. Experts in the field were contacted amplification for the treatment of screening-detected hearing loss. for additional information behind that included in the published The study by Mulrow et al. (12) was a randomized controlled trial on report of the trials. Two review authors worked independently to treatment for hearing loss in older adults. It assessed whether extract data and assess the methodological quality of the trials. hearing aids improved the quality of life of elderly people with They included in their review randomized controlled trials of hearing loss. The authors evaluated 194 older male veterans (mean interventions to improve or promote hearing aid use in adults with age: 72 years) who were randomly assigned to immediate hearing acquired hearing loss, compared with usual care or another aids or to a waiting list control for four months. Hearing-related intervention. The authors classified these interventions according to quality of life outcomes were measured using the Hearing Handicap Wagner’s ‘chronic care model’ (14). Two studies addressed the Inventory for the Elderly (HHIE) and the Quantified Denver Scale of effects of self-management support interventions on short- to Communication Function (QDS) at baseline, six weeks, and four medium-term daily hours of hearing aid use but they could not be months. combined in a meta-analysis and were not included in the GRADE tables of this review by WHO. Fitzpatrick (15)enrolled 24 The randomized controlled trial by Yueh et al. (11) enrolled 64 participants ranging in age from 45 to 88 years (14 into the veterans (mean age, 68 years). Those eligible in the United States intervention group, and 10, the control group). She reported that of America for free Veterans Health Administration-issued hearing aids were randomly assigned to a standard non-directional or a (continued next page)

ICOPE guidelines – World Health Organization 6 Evidence profile: hearing loss eight participants (57%) in the auditory training intervention group al. (16) recruited 60 participants (age range: 55 to 81 years; no wore their hearing aids all of the time before, after and during control group) among first-time hearing aid users. They compared a therapy, and six participants (43%) wore hearing aids in a larger pre-fitting demonstration of listening situations against a fitting number of listening situations after therapy. In the control group without this demonstration and reported that four out of 20 who received lectures on hearing loss, hearing aids and participants in the intervention group, and one out of 20 in the communication over the same time period, seven participants (70%) control group wore their hearing aids for more than eight hours per wore their hearing aids all of the time, and three (30%) wore their day. The clinical significance of this result is unclear. aids in limited situations before and after the lectures. Saunders et

ICOPE guidelines – World Health Organization 7 Evidence profile: hearing loss

GRADE table 1: Screening for hearing loss versus no screening

Author: WHO systematic review team Date: Between 1st October and 15th November 2015 Question: Screening for hearing loss compared with no screening for older people with hearing loss Setting: Primary care or community Bibliography: Yueh B, Collins MP, Souza PE, et al. Long-term effectiveness of screening for hearing loss: the Screening for Auditory Impairment – Which Hearing Assessment Test (SAI- WHAT) randomized trial. J Am Geriatr Soc. 2010;58:427–34.

Quality assessment Number of patients Effect

Number Screening Quality Importance Study Risk of Other No Relative Absolute of Inconsistency Indirectness Imprecision for hearing design bias considerations screening (95% CI) (95% CI) studies loss

Hearing aid use (follow up 1 year; assessed with self-report and direct observation)

1 randomized not not serious serious a not serious yes b 34/459 30/923 RR 2.28 42 more  CRITICAL (7.4%) (3.3%) (1.41 to per 1000 LOW trials serious 3.68) (from 13 more to 87 more) a Indirectness: Downgraded once as all participants in the trial were eligible to receive free VA-issued hearing aids and trial was carried out in a high-income country. Therefore, generalizing evidence to other settings is questionable. b Other consideration: Downgraded once as evidence is from one trial.

ICOPE guidelines – World Health Organization 8 Evidence profile: hearing loss

GRADE table 2: Screening and provision of hearing aids

Author: WHO systematic review team Date: Between 1 October and 15 November 2015 Question: Provision of hearing aid or assistive listening device compared with no hearing aid or assistive listening device for older people with hearing loss Setting: Primary care or community Bibliography: Mulrow CD, Aguilar C, Endicott JE, et al. Quality-of-life changes and hearing loss: a randomized trial. Ann Intern Med. 1990; 113(3):188–94. Yueh B, Souza PE, McDowell JA, et al. Randomized trial of amplification strategies. Arch Otolaryngol Head Neck Surg. 2001; 127(10):1197–204.

Quality assessment Number of patients Effect

Provision of No hearing aid Quality Importance Number Study Risk of Other hearing aid or Absolute Inconsistency Indirectness Imprecision or assistive of studies design bias considerations assistive (95% CI) listening device listening device

Social function (follow up 3–4 months; assessed with Hearing Handicap Inventory; lower score = better performance)

2 randomized serious a serious b serious c not serious none 106 111 MD 33.4  CRITICAL trials higher VERY LOW (27.2 higher to 39.6 higher )

Depression (follow up 4 months; assessed with Geriatric Depression Rating Scale; lower score = better performance)

1 randomized not not serious serious d serious e none 95 99 MD 0.8 higher  IMPORTANT trials serious (0.09 higher to LOW 1.5 higher) (continued next page)

ICOPE guidelines – World Health Organization 9 Evidence profile: hearing loss

Communication (follow up 4 months; assessed with Quantified Denver Scale; lower score = better performance)

1 randomized not not serious serious d serious e none 95 99 MD 24 higher  CRITICAL trials serious (17 higher to LOW 31 higher) a Risk of bias: Downgraded once as low to follow-up and intention to treat analysis was not described clearly in Yueh 2001 trial. b Inconsistency: Downgraded once as substantial heterogeneity was observed (Chi² = 6.14, df = 1 (P= 0.01); I² = 84%. No subgroup analysis was performed and we were not able to explain the heterogeneity. c Indirectness: Downgraded once as trial participants were mostly white male veterans in one trial and in other restricted to patient who are eligible for free hearing aids d Indirectness: Downgraded once as participants in the trial were mostly white male veterans e Imprecision: Downgraded once as sample size was small (smaller than 200)

ICOPE guidelines – World Health Organization 10 Evidence profile: hearing loss

GRADE table 3: Self-management support compared with control (alternative interventions)

Author: WHO systematic review team Date: Between 1st October and 15th November 2015 Question: Self-management support interventions compared with alternative interventions that control for other elements delivery method/pattern for adults with hearing loss who use hearing aids Setting: Hospital Bibliography: Barker F, Mackenzie E, Elliott L, Jones S, de Lusignan S. Interventions to improve hearing aid use in adult auditory rehabilitation. Cochrane Database Sys Rev. 2014(7):CD010342. doi:10.1002/14651858.CD010342.pub2.

Quality assessment Number of patients Effect

Alternative self- interventions that Quality Importance Number of Study Risk of Other management Absolute Inconsistency Indirectness Imprecision control for other studies design bias considerations support (95% CI) elements delivery interventions method/pattern

Quality of life (follow-up 12 months; assessed with validated self-report measures (WHO); lower score = better performance)

1 randomized serious a not serious serious b serious c none 17 18 MD -9.1 lower  IMPORTANT trials (-21.33 lower to VERY 3.13 higher) LOW

Self-reported hearing handicap (follow-up 12 months; assessed with validated self-report measure (HHIE); lower score = better performance)

2 randomized serious d not serious not serious serious e none 43 44 MD -12.8 lower  IMPORTANT trials (-23.11 lower to LOW -2.48 lower) (continued next page)

ICOPE guidelines – World Health Organization 11 Evidence profile: hearing loss

Use of verbal communication strategy (follow-up 12 months; assessed with validated self-reported measure: verbal subscale of the CPHI; higher score = better performance)

1 randomized serious f not serious not serious serious g none 26 26 MD 0.72 higher  IMPORTANT trials (0.21 higher to LOW 1.23 higher)

MD – mean difference; RR – relative risk a Risk of bias: Downgraded once as outcome assessor were not masked due to the nature of the intervention. b Indirectness: Downgraded once as trial participants were mainly military veterans. Therefore, generalising the evidence to other populations is questionable. c Imprecision: Downgraded once as sample size was small (less than 200). d Risk of bias: Downgraded once as outcome assessor was masked in one of the included trials. e Imprecision: Downgraded once as sample size was small (less than 200). f Risk of bias: Downgraded once as allocation was unclear. g Imprecision: Downgraded once as sample size was small (less than 200).

ICOPE guidelines – World Health Organization 12 Evidence profile: hearing loss

Part 2: From evidence to recommendations

Summary of evidence

Outcome Effect size

Screening for hearing loss Screening and provision of Self-management support vs. no screening hearing aid or assistive interventions vs. alternative listening device vs. no interventions hearing aid or assistive listening device

Use of hearing aid RR 2.28 (1.41 to 3.68) – – GRADE table 1; Yueh et al. (10) Favours Intervention LOW

Social and emotional function – MD 33.4 higher – (HHIE score) (27.2 higher to 39.6 higher) GRADE table 2; Mulrow et al. (12) Favours intervention and Yueh et al. (11) VERY LOW

Depression (GDS) – MD 0.8 higher – GRADE table 2; Mulrow et al. (12) (0.09 higher to 1.5 higher) and Yueh et al. (11) Favours intervention LOW

Use of verbal communication – MD 24 higher – strategy (17 higher to 31 higher)

GRADE table 2; Mulrow et al. (12) Favours intervention and Yueh et al. (11) LOW (continued next page)

ICOPE guidelines – World Health Organization 13 Evidence profile: hearing loss

Quality of life – – MD 9.1 lower GRADE table 3; Barker et al. (13) (21.33 lower to 3.13 higher) VERY LOW

Self-reported hearing handicap – – MD 12.8 lower GRADE table 3; Barker et al. (13) (23.11 lower to 2.48 lower) Favours intervention LOW

Use of verbal communication – – MD 0.72 higher strategy (0.21 higher to 1.23 higher) GRADE table 3; Barker et al. (13) Favours intervention LOW

Evidence-to-recommendations table

Problem Explanation

Is the problem a priority? One-third of older people aged 65 years and over live with some degree of hearing loss. In older people, hearing loss is strongly associated with reduced functional ability, social isolation, Yes No Uncertain depression, cognitive decline, poor quality of life, and need for formal and informal care

✓ services. Therefore, provision of screening and adequate services at primary care or community setting is essential. (continued next page)

ICOPE guidelines – World Health Organization 14 Evidence profile: hearing loss

Problem Explanation

Do the desirable effects outweigh the There is very limited, low quality evidence that suggests that case-finding for hearing loss undesirable effects? improves the use of hearing aids among older people with hearing loss. One randomized controlled trial that enrolled 2 305 participants found that screening was associated with a Yes No Uncertain significant increase in hearing aid use at one year compared with no screening.

✓ There is limited low quality evidence on the effectiveness of case-finding through targeted

screening and provision of hearing aids for older adults with hearing loss. Two trials that investigated the immediate provision of hearing aids, after screening for hearing loss, found significant and considerable improvements in hearing-related outcomes. However, these findings came from studies that recruited mostly Caucasian male veterans. Participants in the intervention groups qualified to receive free hearing aids.

There is limited low quality evidence to suggest that a self-management support intervention is effective in improving uptake or use of hearing aids in older adults with hearing loss. However, the effect sizes were small and not clinically significant, and the overall sample size was small.

We identified no studies on the harms associated with the screening or provision of hearing aids for hearing loss in older people. Harms are unlikely to be greater than minimal because screening and confirmatory testing are non-invasive and treatment with hearing aids is not associated with significant harms. (continued next page)

ICOPE guidelines – World Health Organization 15 Evidence profile: hearing loss

Values and preferences/ acceptability Explanation

Is there important uncertainty or variability Hearing loss has a dramatic impact on both the quality of life and ability to function in older about how much people value the adults. Case-finding and provision of care, and supportive education interventions to promote options? the use of hearing aids may have a positive impact on older people who adhere to the use of hearing aids. Therefore, the GDG believes that this recommendation is likely to be valued by Major Minor Uncertain variability variability older people with hearing loss and stakeholders.

✓

Is the option acceptable to key stakeholders? Major Minor Uncertain variability variability

✓

Feasibility / resource use Explanation

How large are the resource Most of the interventions evaluated in the trials were resource intensive. Screening and requirements? provision of hearing aid technology require economic and human resources (training) that might not readily available in all countries. No data were obtained on the rates of hearing aid use in Major Minor Uncertain ✓ low- and middle-income countries where access to hearing aid technology presents more of a

challenge. The GDG believes that it is feasible to implement community case-finding and provision of hearing aids at primary care or community level. Is the option feasible to implement? Yes No Uncertain

✓ (continued next page)

ICOPE guidelines – World Health Organization 16 Evidence profile: hearing loss

Equity Explanation

Would the option improve equity in The provision of, or prescription for, hearing aids already exists in clinical practice in most health? countries. However, in low- and middle-income countries there is a large service gap among older people because many of them have difficulties in accessing the hearing health services. Yes No Uncertain The GDG firmly believe that promoting community case-finding and immediate provision of

hearing aids is likely to reduce inequality in care services. ✓

ICOPE guidelines – World Health Organization 17 Evidence profile: hearing loss

Guideline development group recommendation and remarks

Recommendation

Screening followed by provision of hearing aids should be offered to older people for timely identification and management of hearing loss. Strength of the recommendation: Strong Quality of evidence: Low

Remarks

• Due to the paucity of the evidence, the direct benefit of community case finding through targeted screening for hearing loss among older people is unclear. • Hearing aids should only be fitted after an audiometric assessment. • Treatable ear conditions/medical pathologies should be ruled out before amplification devices are offered. • A thorough ear examination is essential before undertaking hearing-aid fitting, including ear wax removal. • The hearing aid should be appropriate for the person with hearing loss and should be properly fitted. • The hearing aids recommended should be in line with the WHO’s rehabilitation guidelines and preferred assistive product profile. • Close attention should ensure that instrument cases do not cause skin abrasion or irritation with long-term usage. • A referral should be made if the prospective user has aural discharge, pain or discomfort in the ear, acute or chronic dizziness, unilateral hearing loss, or sudden onset of severe tinnitus. • Hearing-aid provision should be accompanied by follow-up services and easy access to services for replacement of batteries, ear moulds, and maintenance and repair of hearing aids. • Self-support educational intervention should be considered when administering hearing aids to older people with hearing loss.

ICOPE guidelines – World Health Organization 18 Evidence profile: hearing loss

References

1. Hearing loss in persons 65 years and older. In: Geneva: World 10. Yueh B, Collins MP, Souza PE, Boyko EJ, Loovis CF, Heagerty PJ, Health Organization (WHO) [website]; 2012 Liu C-F, Hedrick SC. Long-term effectiveness of screening for (http://www.who.int/pbd/deafness/estimates, accessed 6 November hearing loss: the screening for auditory impairment-which hearing 2017). assessment test (SAI-WHAT) randomized trial. J Am Geriatr Soc. 2. Dalton DS, Cruickshanks KJ, Klein BE, Klein R, Wiley TL, Nondahl 2010;58(3):427–34. doi:10.1111/j.1532-5415.2010.02738.x. DM. The impact of hearing loss on quality of life in older adults. The 11. Yueh B, Souza PE, McDowell JA, Collins MP, Loovis CF, Hedrick Gerontologist. 2003; 43(5): 661-8. SC, et al. Randomized trial of amplification strategies. Arch 3. Gopinath B, Schneider J, McMahon CM, Teber E, Leeder SR, Otolaryngol Head Neck Surg. 2001;127(10):1197–204. Mitchell P. Severity of age-related hearing loss is associated with doi:10.1001/archotol.127.10.1197. impaired activities of daily living. Age and ageing. 2012; 41(2): 195- 12. Mulrow CD, Aguilar C, Endicott JE, Tuley MR, Velez R, Charlip WS, 200. et al. Quality-of-life changes and hearing impairment: a randomized 4. Limongi F, Noale M, Siviero P, Crepaldi G, Maggi S. Epidemiology trial. Ann Intern Med. 1990;113(3):188–94. doi:10.7326/0003-4819- of aging, dementia and age-related hearing loss. Hearing, Balance 113-3-188. and Communication. 2015; 13(3): 95-9. 13. Barker F, Mackenzie E, Elliott L, Jones S, de Lusignan S. 5. Davis ADKA. Epidemiology of Aging and Hearing Loss Related to Interventions to improve hearing aid use in adult auditory Other Chronic Illnesses In: Hearing Care for Adults 2009. rehabilitation. Cochrane Database Sys Rev. 2014(7):CD010342. 6. Gates GA, Mills JH. Presbycusis. The Lancet. 2005; 366(9491): doi:10.1002/14651858.CD010342.pub2. 1111-20. 14. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care 7. McCormack A, Fortnum H. Why do people fitted with hearing aids for patients with chronic illness. JAMA. 2002;288(14):1775. not wear them? Int J Audiol. 2013 May;52(5):360-8. doi: doi:10.1001/jama.288.14.1775. 10.3109/14992027.2013. 769066. Epub 2013 Mar 11. Review. 15. Fitzpatrick D. Effects of auditory training on speech recognition for 8. Kochkin S. 2012. Hearing loss treatment. Better Hearing Institute. persons with binaural sensorineural hearing loss [thesis]. New York: Available at: New York University; 2008. http://www.betterhearing.org/hearing_loss_treatment/index.cfm 16. Saunders GH, Lewis MS, Forsline A. Expectations, prefitting 9. Deafness and hearing loss: factsheet. In: Geneva: WHO [website]; counseling, and hearing aid outcome. J Am Acad Audiol. 2017 (http://www.who.int/mediacentre/factsheets/fs300, accessed 2009;20(5):320–34. doi:10.3766/jaaa.20.5.6. 25 August 2017).

ICOPE guidelines – World Health Organization 19 Evidence profile: hearing loss

Annex 1: Search strategy (MEDLINE and Embase 2015)

1. exp randomized controlled trial/ 24. 23 not 11 2. exp randomization/ 25. exp comparative study/ 3. exp double blind procedure/ 26. exp evaluation/ 4. exp single blind procedure/ 27. exp prospective study/ 5. random$.tw. 28. (control$ or prospectiv$ or volunteer$).tw. 6. or/1-5 29. or/25-28 7. (animal or animal experiment).sh. 30. 29 not 10 8. human.sh. 31. 30 not (11 or 23) 9. 7 and 8 32. 11 or 24 or 31 10. 7 not 9 33. exp hearing test/ 11. 6 not 10 34. ((hear or hearing$) adj5 (screen* or assess* or test* or 12. exp clinical trial/ diagnos* or surveill*)).tw. 13. (clin$ adj3 trial$).tw. 35. hearing adj1 aid.tw 14. ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$)).tw. 36. (assistive adj 1(listening or device)).tw 15. exp placebo/ 37. or/33-36 16. placebo$.tw. 38. exp aged/ 17. random$.tw. 39. exp senescence/ 18. exp experimental design/ 40. exp elderly care/ 19. exp crossover procedure/ 41. (old$ adj5 (age$ or people or person$)).tw. 20. exp control group/ 42. (geriatric$ or elderly or senior$).tw. 21. exp latin square design/ 43. or/38-42 22. or/12-21 44. 32 and 47 and 43 23. 22 not 10

ICOPE guidelines – World Health Organization 20 Evidence profile: hearing loss

Annex 2: PRISMA2 flow diagram for hearing screening and referral

Records identified through Additional records identified database searching through other sources (n = 1780) (n = 1)

Identified

Records after duplicates removed

(n = 1781)

Records excluded (n = 1771):

Screened Records screened Wrong intervention: 1230 (n = 1781) Wrong study design or publication type: 139 Conference abstract: 143

Full-text articles assessed for eligibility Full-text articles excluded, with reasons (n = 3): (n = 10) Outcome not reported (n = 2)

Target population under 60 years of age

Eligible

Systematic reviews Additional randomized controlled trials included in included (n = 1) quantitative synthesis (meta-analysis)

(n = 4) Included

______

2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). For more information: http://www.prisma-statement.org

ICOPE guidelines – World Health Organization