Perceived Quality of Life Among Adults With Hearing Loss: Relationships With Amplification Device and Financial Well-Being

Abstract

The current study explored the relationship between perceived quality of life and financial well-being among adult cochlear implant (CI) users as compared with hearing aid (HA) users. Participants were 66 adults: 30 CI users and 36 HA users. They completed the Perceived Quality of Life for Deaf and Hard-of-Hearing (DHH) scale, the In Charge Financial Distress/Financial Well-Being scale, and a background questionnaire. Significant differences were found between the two study groups in two perceived quality-of-life factors: participation, t(58) = 1.71, p < .05, and perceived stigma, t(58) = −1.80, p < .05. CI users reported higher levels of participation and lower levels of perceived stigma as compared with HA users. In addition, financial well-being was a significant predictor of participation (β = .32, p < .05), and CI users who used their device for a longer time reported higher levels of financial well-being (r = .35, p < .05). Research findings emphasize the possible contribution that both CIs and financial well-being may have on the perceived quality of life of DHH adults. In addition, time since implantation may be an important variable when measuring improvements after cochlear implantation, especially when evaluating long-term processes, such as changes in financial well-being.

Keywords

deafness disability(ies)sensory impairments

Hearing loss can affect the development of speech and spoken language through communication skills, interpersonal relationships, and social development, adversely affecting well-being (Gilman, Easterbrooks, & Frey, 2004; Leigh, Maxwell-McCaw, Bat-Chava, & Christiansen, 2009). Communication challenges may also affect a person’s perceived quality of life as well as their physical, emotional, and psychological functioning (Leigh, 1999, 2009; Stinson & Liu, 1999). A major factor which may influence the communication of individuals with hearing loss within the hearing world is their amplification device. The current study examined the quality of life of deaf and hard-of-hearing (DHH) adults with and without cochlear implants (CIs). In this study, the term DHH refers to hearing status and not to cultural affiliation (i.e., belonging to the deaf or the hearing community).

CIs are recognized as providing individuals who have limited hearing with considerably more auditory information than what is available with hearing aids (HAs; Thoutenhoofd et al., 2005; Uziel et al., 2007). For individuals with thresholds in the severe hearing loss range, conventional HAs can provide satisfactory access to the speech spectrum in the low to mid-frequencies but provide insufficient gain in the high-frequency range beyond about 3,000 Hz (Boothroyd, 2008).

Experimental studies strongly suggest that speech perception and speech reading improve significantly after cochlear implantation (e.g., Santarelli, De Filippi, Genovese, & Arslan, 2008; Tyler, Parkinson, Woodworth, Lowder, & Gantz, 1997). There is also evidence that children with CIs perform better in many aspects of spoken language than children of similar hearing loss level who use HAs (e.g., Blamey et al., 2001). In addition, children who have grown up with CIs are quite likely to read at grade level and to achieve scores on academic tests that are equivalent or close to those of their hearing peers (Chute, 2012; Spencer, Barker, & Tomblin, 2003; Spencer, Gantz, & Knutsen, 2004; Uziel et al., 2007). Another by-product of the advent of CIs has been an increased propensity of DHH children to participate in mainstream educational environments (Huber, Wolfgang, & Klaus, 2008; Waltzman, Cohen, Green, & Roland, 2002).

All of these benefits suggest that quality of life improves after cochlear implantation, a finding which has been reported in several studies (e.g., Ángel et al., 2013; Meserole et al., 2014). However, one should keep in mind that there is an ongoing debate regarding cochlear implantation, especially by nonhearing parents who perceive deafness as a cultural affiliation and not as a disability that should be “fixed” (e.g., Mauldin, 2014). Thus, there is great importance in examining diverse aspects of potential benefits, including subjective perceptions, when considering the advantages (or disadvantages) of CIs.

In general, research on quality of life of DHH individuals has focused mainly on health-related quality-of-life (HRQOL) measures based on physical, emotional, and psychological functioning (Hawthorne et al., 2004; Huber, 2005; Karinen, Sorri, Valimaa, Huttunen, & Löppönen, 2001; Wake, Hughes, Collins, & Poulakis, 2004). In addition, quite often, research on DHH individuals does not tap into the subjective aspects of the impact of speech, hearing, language, and academic skills on quality of life. The present study focused on perceived quality of life, including aspects of communication, social interaction, and participation that may be important for well-being (Schick et al., 2012).

Perceived Quality of Life Among DHH Adults

According to the World Health Organization, “Quality of life is defined as individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns” (World Health Organization Quality of Life Assessment Instrument Group, 1994, p. 1403). This definition emphasizes the subjectivity of the term. Quality-of-life questions often focus on the self, social relationships, and a person’s relationship with his or her environment. There is also condition-specific quality of life that attempts to capture concepts and domains of quality of life that are specific to a group. In the case of DHH individuals, this refers not only to their ability to hear but also to broader quality-of-life issues, such as the ability to successfully interact with peers and family (regardless of hearing ability), and to maintain psychosocial, emotional, and academic development (Gilman et al., 2004; Hintermair, 2011; Kushalnagar et al., 2011; Lin & Niparko, 2006).

When previous research investigated quality of life for DHH individuals, often only generic instruments were used (i.e., instruments measuring overall quality of life), which may not capture issues that are unique to a DHH person such as communication, social interaction, and participation (Lin & Niparko, 2006; Schick et al., 2012). Or as stated by Roland and colleagues (2016), although multiple quality-of-life assessment tools have been used to evaluate pediatric hearing impairment, few were designed to specifically address this problem. Recently, however, more and more researchers are starting to pay attention to such issues especially when examining youth (e.g., Kushalnagar et al., 2011; Patrick et al., 2011; Schick et al., 2012). The current study’s authors adopt this approach in relation to DHH adults as well.

Studies on the quality of life among DHH adults are generally sparse, focus mostly on the elderly sector of the population (Dalton et al., 2003; Hogan, O’Loughlin, Miller, & Kendig, 2009; Pugh & Crandell, 2002), and tend to examine general quality of life along with hearing qualities such as auditory performance (e.g., Vannson et al., 2015). Ringdahl and Grimby (2000) have studied the HRQOL in elderly adults with severe-profound hearing loss. They reported that, in general, participants with severe to profound hearing loss constitute a potential risk group for general deterioration in HRQOL as compared with the typical hearing population. However, participants who were fully employed reported a better HRQOL than individuals with similar hearing loss who were retired. The authors concluded that level of education, job employment, and a strong will power all influence each other, and are related to maintaining HRQOL. The current study’s authors follow this conclusion by examining a potential by-product of education and employment: financial well-being (e.g., Chan, Chau, & Chan, 2012), and its relationship with perceived quality of life. In addition, and in contrast to Ringdahl and Grimby’s study, the authors of the present study take into account participants’ amplification device which may affect their level of hearing—having a HA or a CI.

Financial Well-Being Among DHH Adults

Financial well-being is a multifaceted concept that transcends both traditional financial literacy and the broader notion of financial capability. According to the Consumer Financial Protection Bureau (2015), financial well-being entails having control over one’s finances day to day and month to month, having the capacity to absorb financial shocks, being on track to meet financial goals, and having the financial freedom to make choices that allow one to enjoy life. Most individuals hope to attain financial well-being, yet it eludes many. Differences in access to resources and opportunities are no doubt responsible for much of the variation in financial well-being across individuals (Drever et al., 2015).

Evidence indicates that having a hearing loss may impose difficulties in attaining financial well-being. For example, relative to their hearing peers, DHH adults tend to experience more unemployment and underemployment, and to have lower incomes (Bradley, Ebener, & Geyer, 2013; Smith, 2011; Winn, 2007). Lower retention and graduation rates from postsecondary education and training opportunities further reduce the representation of these students in the workforce (Wagner, Newman, Cameto, Levine, & Garza, 2006).

There may be several reasons for the educational and occupational challenges of many DHH individuals. First of all, these challenges are probably related to prior academic experience. It is well known that in general, children with severe and profound hearing loss tend to encounter substantial difficulties in most areas of academic performance as well as in spoken language development (Lollis & LaSasso, 2009; Traxler, 2000). These academic difficulties may extend into adulthood in the form of lower postsecondary education attendance and lower income (Bullis, Davis, Bull, & Johnson, 1997; Luckner, 2002; Punch, Hyde, & Creed, 2004). Second, persons with hearing loss are likely to encounter environmental and attitudinal barriers that can impede their achievement of educational and career outcomes (Punch et al., 2004). The functional effects of hearing loss and other people’s negative attitudes have created career barriers for many people who are DHH (Punch et al., 2004; Stika, 1997). Furthermore, the effects of their hearing loss may be perceived by young people and by important others such as parents, teachers, and potential employers as a limitation in regard to the accessibility of many occupations (Weisel & Cinamon, 2005).

Although many DHH individuals may encounter major occupational-related challenges, this may not be the case for CI users due to the auditory and speech perception benefits that CIs provide (e.g., Santarelli et al., 2008; Uziel et al., 2007). However, not much is known about the functioning of adults with CI, especially with regard to occupational and financial achievements. Fazel and Gray (2007), for example, found that cochlear implantation was associated with an improved chance of being employed. It also helped with improved job satisfaction as well as improved employee perception of their career prospects. However, they did not examine financial well-being and its relationship with perceived quality of life.

Although the aim of cochlear implantation is to restore auditory functions in patients with profound hearing loss, it is still difficult to predict how an individual will perform postoperatively (Hallberg & Ringdahl, 2004), and how this may affect his or her quality of life. Studies on speech perception abilities have shown that most improvements occur within the first year (e.g., Hamzavi, Baumgartner, Pok, Franz, & Gstoettner, 2003) or up to 2 years (Ruffin et al., 2007; Tyler et al., 1997). Following these findings, in the current study perceived quality of life and its relationship with financial well-being were examined among adults who used CIs for 1.5 years or more compared with adults with HAs.

In light of the various benefits that have been reported in relation to CIs (e.g., Ángel et al., 2013; Meserole et al., 2014) and due to the lack of research on aspects of quality of life of DHH individuals, the purpose of the current study was to explore the relationship between perceived quality of life and financial well-being among adult CI users as compared with HA users. Specifically, research goals were to examine (a) differences between CI and HA users in their perceived financial well-being and quality of life, and (b) the contribution of amplification device and financial well-being to participants’ perceived quality of life. A secondary goal was to explore the relationships between time since implantation and perceived quality of life and financial well-being among CI users.

Method

Participants

Participants were 66 adults aged 21 to 74 (M = 42.91, SD = 14.82). Thus, in contrast to previous studies on DHH adults (e.g., Hogan et al., 2009), a wide range of participants with different age groups were examined. Thirty participants were CI users, and 36 participants were HA users. All participants with CIs were implanted after age 3 and had been using the implant for at least a year and a half (M = 8.30, SD = 5.99). Most of them (n = 28) were implanted in one ear, and two had two implants (both had undergone a sequential procedure). Table 1 presents additional demographic data on the participants.

Table 1.

Demographic Data of the Study Groups.

Variable	Categorical level	CI users (n = 30)		HA users (n = 36)
Variable	Categorical level	Frequency	%	Frequency	%
Gender	Men	11	37	14	39
Gender	Women	19	63	22	61
Religion	Jewish	29	97	33	91
Religion	Muslim	1	3	3	9
Family status	Single	11	35	9	25
	Married	14	48	21	59
	Divorced	4	14	5	13
	Widowed	1	3	1	3
Education	Elementary	1	3	—	—
	Secondary	8	28	8	21
	Postsecondary vocational	2	7	8	21
	Academic	19	62	20	58
Degree of hearing loss	Moderate	—	—	3	9
	Severe	12	41	22	70
	Profound	18	59	7	21
Congenital hearing loss	Yes	16	53	20	56
Congenital hearing loss	No	14	47	16	44
Mode of communication	Spoken language	27	90	27	73
	Sign language	1	3	1	3
	Total communication	2	7	8	23

Note. CI = cochlear implant; HA = hearing aid.

To determine whether the study groups (CI and HA users) were equivalent for comparison, chi-square analyses were conducted on their demographic data. No significant differences were found apart from degree of hearing loss. Not surprisingly, whereas most of the CI users had profound hearing loss, most of the HA users had severe hearing loss, χ²(2) = 10.67, p < .01.

Instruments

Perceived quality of life for DHH

An instrument was used that was based on the Youth Quality of Life–Deaf and Hard-of-Hearing (YQoL-DHH; Patrick et al., 2011) scale which is a validated quality of life instrument specific to DHH youth between the ages 11 and 19 years. The instrument contains 32 items assessing youth quality of life as a DHH person in three domains: participation (taking part in community activities; 10 items, for example, “I feel it is hard to participate in large groups”), self-acceptance and advocacy (happy with who I am and speaking up for myself; 14 items, for example, “I feel okay explaining to others that I am DHH”), and perceived stigma (perception of discrimination; eight items, for example, “I feel people who are hearing treat me badly”). Respondents are requested to rate their agreement regarding each of the 32 items on a 10-point Likert-type scale ranging from 0 (“Not at all”) to 9 (“Very much”). Mean scores were calculated for each of the three domains.

In the current study, five items were rephrased to suit adults: The word “teacher” in two items was changed into “college teacher/employer,” the word “parents” in two items was changed into “family,” and the words “students at my school” which appeared in one item were changed into “people.” An orthogonal factor analysis suggested a three-factor solution with items pertaining to self-acceptance and advocacy, perceived stigma, and participation domains grouped into separate factors.

Psychometric analyses of the YQoL-DHH perceptual scales by Patrick and colleagues (2011) have yielded scores with acceptable internal consistency (Cronbach’s alpha = .84–.86). In the current study, alphas ranged between .82 and .88.

The In Charge Financial Distress/Financial Well-Being (IFDFW) scale

This eight-item scale (Prawitz et al., 2006) was designed to measure one’s financial state on a continuum ranging from overwhelming financial distress/lowest level of financial well-being (0) to no financial distress/highest level of financial well-being (10; for example, “How often do you worry about being able to meet normal monthly living expenses?”). An index score was obtained by calculating the mean response on the eight items. Principal components analysis indicated that the eight items could be reduced to one component, accounting for 78.9% of the variance. Cronbach’s alpha was .96 in the original study and .94 in the current study.

Background questionnaire

Data were collected on gender, age, religion, family status, level of education, onset of hearing loss, degree of hearing loss, and use of amplification device (CI and/or HA). In addition, CI users were asked about implantation (age when implanted, ear implanted, and type of procedure).

Procedure

The CI users were patients from a CI center in a hospital located at central Israel. They were approached after receiving an approval from the Ministry of Health and the hospital authorities. Of the 36 adults with CIs asked to complete the questionnaires, 30 agreed. Thus, the return rate was 83%.

Some of the HA users were approached through two colleges which include programs for DHH students. Among 19 students registered for the programs, 11 agreed to complete the questionnaires. Thus, the return rate from the colleges was 58%. In addition, two large organizations for DHH people in Israel distributed the research questionnaires via their website, yielding an additional 25 completed questionnaires.

Participants completed the questionnaires in approximately 15 to 30 min. They were offered help if they had trouble understanding questions; however, no major difficulties arose. No incentives were provided to the participants.

Data Analysis

Several data analyses were conducted. First, means and standard deviations were calculated for each of the study’s variables for the whole sample and for both of the research groups to gain a general picture. Pearson’s correlations were also calculated to examine the relationships between the variables. Differences between CI and HA users were measured using independent samples t tests. In addition, linear regression analyses were conducted to examine the contribution of amplification device and financial well-being to participants’ perceived quality of life. The relationships between time since implantation and quality of life and financial well-being were examined using Pearson’s correlations.

Results

Table 2 presents means, SDs, and intercorrelations for the main study variables among the entire sample and for both subgroups. Participants reported relatively low levels of perceived stigma and relatively high levels of self-acceptance and advocacy (mean scores around 3 and 7, respectively, on a 0–9 scale). Levels of participation (mean scores around 5 on a 0–9 scale) and financial well-being (mean scores around 5 on a 0–10 scale) were moderate. In addition, significant positive correlations were found between financial well-being and participation among the HA group, and between financial well-being and self-acceptance and advocacy among the CI group. These correlations were also significant for the entire sample.

Table 2.

Means, Standard Deviations, and Intercorrelations of the Main Study Variables Among the Whole Sample (N = 66) and Among the CI (n = 30) and the HA (n = 36) Groups.

Variable	Group	M	SD	2	3	4
1. Financial well-being	CI	5.40	2.63	.28	.39*	−.23
	HA	4.97	2.40	.37*	.19	−.12
	Total	5.17	2.50	.36**	.29*	−.22
Perceived quality of life
2. Participation	CI	5.22	2.22		−.01	−.58**
	HA	4.14	2.22		.26	−.53**
	Total	4.68	2.26		.11	−.58**
3. Self-acceptance and advocacy	CI	7.74	1.66			.02
	HA	7.70	1.60			−.53**
	Total	7.72	1.61			−.22
4. Perceived stigma	CI	2.46	2.17
	HA	3.54	2.10
	Total	3.00	2.18

Note. CI = cochlear implant; HA = hearing aid.

p < .05. **p < .01.

One goal of the study was to examine differences among CI and HA users in perceived quality of life and financial well-being. Independent samples t tests revealed significant differences in two of the three subscales of the quality-of-life measure: participation, t(58) = 1.71, p < .05, and perceived stigma, t(58) = −1.80, p < .05. As presented in Table 2, CI users reported higher levels of participation and lower levels of perceived stigma compared with HA users. No significant differences were found between the two groups in their financial well-being, t(64) = 0.70, p = .24.

Another goal of the study was to examine the contribution of amplification device and financial well-being to participants’ perceived quality of life. As not all of the perceived quality-of-life subscales were significantly correlated (see Table 2) and due to sample size, it was decided to conduct three linear regressions for each of the perceived quality of life for DHH variables. In all of these regressions, amplification device (CI or HA) was entered in the first step, and perceived quality of life was entered in the second step.

A significant result was found only in relation to participation, F(2, 63) = 4.37, p < .05, f² = .19. Type of amplification device and financial well-being explained 16% of the variance in participation, with amplification device explaining 6% and financial well-being explaining the remaining 10%. Financial well-being was found to be a significant predictor of participation (β = .32, p < .05). Higher levels of financial well-being were related to higher levels of participation (see Table 2).

In addition, the relationships between time since implantation and quality of life and financial well-being were examined among the CI users. A significant positive correlation was found between time since implantation and financial well-being (r = .35, p < .05).

Discussion

Studies on the quality of life among DHH adults are sparse and tend to examine general quality of life along with hearing qualities. In addition, many of them disregard other variables which may affect quality of life among DHH individuals such as type of amplification device and financial situation. The purpose of the current study was to explore the contribution of CIs and financial well-being to the perceived quality of life of adults with hearing loss.

In general, participants reported relatively moderate to high levels of perceived quality of life (relatively low levels of perceived stigma, high levels of self-acceptance and advocacy, and moderate levels of participation). Levels of financial well-being were moderate. However, some significant differences did emerge from the two study groups—CI users reported higher levels of participation and lower levels of perceived stigma compared with HA users. These findings are in accordance with previous studies in which improved functioning following cochlear implantation (e.g., Santarelli et al., 2008) as well as general quality of life (e.g., Hawthorne et al., 2004) were reported. They also imply that, at least in certain aspects, CI users perceive their quality of life as better than HA users.

A possible explanation for the fact that adults with CIs reported more participation and less perceived stigma may be related to the improvement in hearing and communication skills that CIs can provide compared with the auditory information available with HAs (e.g., Uziel et al., 2007). These findings follow results of studies conducted on children with CIs who reported an increased propensity to participate in mainstream educational environments (e.g., Huber et al., 2008). It seems that adults, as well as children, who are implanted tend to participate more in their social surroundings, which include for most of them interacting with hearing persons (Mitchell & Karchmer, 2004). This participation, together with improved spoken language skills, may decrease the negative attitudes hearing persons may hold toward them.

Interestingly, no significant differences were found between the two study groups (CI and HA users) in self-acceptance and advocacy and in financial well-being. The lack of difference in self-acceptance and advocacy may be explained by the fact that the participants were adults. According to various developmental approaches, issues of identity are most typical during adolescence. For example, Erikson (1968) claimed that during adolescence individuals try to figure out what is unique or distinctive about themselves. By the time they reach adulthood, they are likely to have a more stable identity, and a better understanding of their own strengths and difficulties. Consequently, it is logical to assume that they tend to accept themselves and know how to protect their interests better than they did when they were younger, regardless of their hearing and oral communication abilities.

As for the lack of significant difference in financial well-being between CI and HA users, this finding is in contrast to Fazel and Gray’s study (2007) who found that cochlear implantation was associated with job-related variables such as an improved chance of being employed and improved job satisfaction. Nonetheless, one should keep in mind that financial well-being is not necessarily related to the type of job an individual may hold. Rather, it is the sense of control over one’s financial status. It may be that as DHH individuals in general tend to have lower incomes (e.g., Bradley et al., 2013), they also tend to have similar financial well-being. Another explanation may simply be related to the sample size. As there appeared a substantial but nonsignificant difference in financial well-being between the two groups, it could be that a larger sample may have elicited statistical significance. Future studies should examine financial well-being among DHH and typical hearing adults using larger samples to attain firmer conclusions on the matter.

In general, perceived quality of life was associated with financial well-being. Statistically significant associations were found in relation to two of the three perceived quality-of-life factors: participation and self-acceptance/advocacy. As expected, higher levels of financial well-being were related to higher levels of these quality-of-life factors. However, when each study group was examined separately, only one significant correlation was found in each group: between financial well-being and participation among the HA group, and between financial well-being and self-acceptance and advocacy among the CI group. These correlations, together with the fact that there were significant differences between the two study groups in perceived quality of life (participation and perceived stigma), may suggest that both amplification device and financial well-being are related to aspects of perceived quality of life, but that each of them is related to different aspects.

Interestingly, when the contribution of both types of amplification device and financial well-being to participants’ perceived quality of life was examined, a significant result emerged only in relation to participation, with financial well-being being a significant predictor. This finding may imply that although significant differences were found between the study groups in certain aspects of perceived quality of life, these differences may not be due to amplification device per se. As in this study participants were similar in their demographic data, future studies should examine other variables that may be related to having a CI of a HA, such as levels of speech perception (e.g., Santarelli et al., 2008) and academic performance (e.g., Chute, 2012).

Examination within the CI group elicited a significant association between time since implantation and financial well-being. Participants who used CIs for a longer time reported higher levels of financial well-being. Interestingly, no significant correlations were found between time since implantation and perceived quality of life. A possible explanation for this may be related to the fact that all CI users in this study used their implants for at least 1.5 years. As most gains in performance tend to occur in the first 9 to 12 months of use of the CI (Tyler et al., 1997), it might be that no major improvements in quality of life had occurred for these participants at the time they filled out the research questionnaires. In contrast, improvements in financial well-being may have taken longer to occur compared with other life domains. Individuals need to operate in their environment, creating and utilizing opportunities, so that they can accumulate wealth and change their financial well-being.

Research findings emphasize the possible contribution that both CIs and financial well-being may have on the perceived quality of life of DHH adults. They also suggest that these two variables are related differently to perceived quality of life. In addition, time since implantation may be an important variable when measuring improvements after cochlear implantation, especially when evaluating long-term processes such as changes in financial well-being.

In general, research findings point to the fact that CIs may improve important aspects of quality of life that are especially relevant to DHH individuals, such as participation in community activities and perceptions of discrimination (e.g., Patrick et al., 2011; Schick et al., 2012). These findings support previous studies which suggest that CIs may help DHH individuals to blend into the hearing world (e.g., Huber et al., 2008; Waltzman et al., 2002). In addition, as participation, as well as self-acceptance and advocacy, was related to financial well-being, it seems that when evaluating perceived quality of life among persons who are DHH it is important to take into account other important factors such as those examined in this study.

Despite its importance, the current study has some limitations as well. First of all, data came from an Israeli sample. Consequently, the results may not reflect other cultures in which issues related to hearing loss may be perceived differently, or in which individuals may have different access to rehabilitation services (for a review, see Borum, 2012). In addition, no comparison was made in this study with participants with typical hearing. Such a comparison would have enriched the study and may have contributed to its conclusions. Second, most participants in this study used spoken language as their main mode of communication. It would be interesting to explore whether similar results will emerge when comparing DHH adults who use mainly sign language. Third, in light of the results, it seems that a more thorough investigation of participants’ characteristics is needed. For instance, measures of speech perception, academic performance, and educational background may have helped explain the study’s results with greater accuracy. Finally, as the CI users were more easily found through a CI center whereas the HA users were more easily found through academic and social organizations for the deaf, this resulted in two different procedures for the two study groups. Future studies aimed at comparing CI and HA users should consider finding more similar procedures when recruiting participants.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Ángel

Guerra-Jiménez

Rodriguez

Borkoski

Falcón

J. C.

Perez

(2013). Cochlear implants in adults over 60: A study of communicative benefits and the impact on quality of life. Cochlear Implants International, 14, 241–245. doi:10.1179/1754762812Y.0000000028

Blamey

P. J.

Sarant

J. Z.

Paatsch

L. E.

Barry

J. G.

Bow

C. P.

Wales

R. J.

. . . Tooher

(2001). Relationships among speech perception, production, language, hearing loss, and age in children with impaired hearing. Journal of Speech, Language, and Hearing Research, 44, 264–285. doi:10.1044/1092-4388(2001/022)

Boothroyd

(2008.). The acoustic speech signal. In Madell

J. R.

Flexer

(Eds.), Pediatric audiology: Diagnosis, technology, and management (pp. 159–167). New York, NY: Thieme Medical Publishers.

Borum

(2012). Perceptions of communication choice and usage among African American hearing parents: Afrocentric cultural implications for African American deaf and hard of hearing children. American Annals of the Deaf, 157(1), 7–15. doi:10.1353/aad.2012.1606

Bradley

C. F.

Ebener

D. J.

Geyer

P. D.

(2013). Contributors to successful VR outcomes among non-Latino (Caucasian) and Latino consumers with hearing loss. Journal of Rehabilitation, 79(2), 24–33.

Bullis

Davis

Bull

Johnson

(1997). Expectations versus realities: Examination of the transition plans and experiences of adolescents who are deaf and adolescents who are hearing. Rehabilitation Counseling Bulletin, 40, 251–264. doi:10.1177/088572880002300102

Chan

S. F.

Chau

W.-L.

Chan

Y.-K.

(2012). Financial knowledge and aptitudes: Impacts on college students’ financial well-being. College Student Journal, 46, 114–132.

Chute

P. M.

(2012). College experience for young adults with hearing loss. Deafness & Education International, 14(1), 60–65.

Consumer Financial Protection Bureau. (2015). Financial well-being: The goal of financial education. Iowa City, IA: Consumer Financial Protection Bureau.

10.

Dalton

D. S.

Cruickshanks

K. J.

Klein

B. E.

Klein

Wiley

T. L.

Nondahl

D. M.

(2003). The impact of hearing loss on quality of life in older adults. The Gerontologist, 43, 661–668. doi:10.1093/geront/43.5.661

11.

Drever

A. I.

Odders-White

Kalish

C. W.

Else-Quest

N. M.

Hoagland

E. M.

Nelms

E. N.

(2015). Foundations of financial well-being: Insights into the role of executive function, financial socialization, and experience-based learning in childhood and youth. The Journal of Consumer Affairs, 49(1), 13–38. doi:10.1111/joca.12068

12.

Erikson

E. H.

(1968). Identity: youth and crisis. Oxford, England: W.W. Norton.

13.

Fazel

M. Z.

Gray

R. F.

(2007). Patient employment status and satisfaction following cochlear implantation. Cochlear Implants International, 8(2), 87–91. doi:10.1002/cii.332

14.

Gilman

Easterbrooks

S. R.

Frey

(2004). A preliminary study of multidimensional life satisfaction among deaf/hard of hearing youth across environmental settings. Social Indicators Research, 66, 143–164. doi:10.1023/B:SOCI.0000007495.40790.85

15.

Hallberg

R.-M.

Ringdahl

(2004). Living with cochlear implants: Experiences of 17 adult patients in Sweden. International Journal of Audiology, 43, 115–121. doi:10.1080/14992020400050016

16.

Hamzavi

Baumgartner

W. D.

Pok

S. M.

Franz

Gstoettner

(2003). Variables affecting speech perception in postlingually deaf adults following cochlear implantation. Acta Oto-Laryngologica, 123, 493–498. doi:10.1080/0036554021000028120

17.

Hawthorne

Hogan

Giles

Stewart

Kethel

White

. . . Taylor

(2004). Evaluating the health related quality of life effects of cochlear implants: A prospective study of an adult cochlear implant program. International Journal of Audiology, 43, 183–192. doi:10.1080/14992020400050026

18.

Hintermair

(2011). Health-related quality of life and classroom participation of deaf and hard-of-hearing students in general schools. Journal of Deaf Studies and Deaf Education, 16, 254–271. doi:10.1093/deafed/enq045

19.

Hogan

O’Loughlin

Miller

Kendig

(2009). The health impact of a hearing disability on older people in Australia. Journal of Aging and Health, 21, 1098–1111. doi:10.1177/0898264309347821

20.

Huber

(2005). Health related quality of life of Austrian children and adolescents with cochlear implants. International Journal of Pediatric Otorhinolaryngology, 69, 1089–1101. doi:10.1016/j.ijporl.2005.02.018

21.

Huber

Wolfgang

Klaus

(2008). Education and training of young people who grew up with cochlear implants. International Journal of Pediatric Otorhinolaryngology, 72, 1393–1403. doi:10.1016/j.ijporl.2008.06.002

22.

Karinen

P. J.

Sorri

M. J.

Valimaa

T. T.

Huttunen

K. H.

Löppönen

H. J.

(2001). Cochlear implant patients and quality of life. Scandinavian Audiology Supplement, 52, 48–50. doi:10.1080/010503901300007047

23.

Kushalnagar

Topolski

Schick

Edwards

Skalicky

Patrick

(2011). Mode of communication, perceived level of understanding and perceived quality of life in youth who are deaf or hard-of-hearing. Journal of Deaf Studies and Deaf Education, 16, 512–523. doi:10.1093/deafed/enr015

24.

Leigh

(1999). Inclusive education and personal development. Journal of Deaf Studies and Deaf Education, 4, 236–245. doi:10.1093/deafed/4.3.236

25.

Leigh

I. W.

(2009). A lens on deaf identities. New York, NY: Oxford University Press.

26.

Leigh

I. W.

Maxwell-McCaw

Bat-Chava

Christiansen

(2009). Correlates of psychosocial adjustment among deaf adolescents with and without cochlear implants: A preliminary investigation. Journal of Deaf Studies and Deaf Education, 14, 244–259. doi:10.1093/deafed/enn038

27.

Lin

F. R.

Niparko

J. K.

(2006). Measuring health-related quality of life after pediatric cochlear implantation: A systematic review. International Journal of Pediatric Otorhinolaryngology, 70, 1695–1706. doi:10.1016/j.ijporl.2006.05.009

28.

Lollis

LaSasso

(2009). The appropriateness of the NC state-mandated reading competency test for deaf students as a criterion for high school graduation. Journal of Deaf Studies and Deaf Education, 14, 76–98. doi:10.1093/deafed/enn017

29.

Luckner

(2002). Facilitating the transition of students who are deaf or hard-of-hearing. Austin, TX: Pro-Ed.

30.

Mauldin

(2014). Precarious plasticity: Neuropolitics, cochlear implants, and the redefinition of deafness. Science, Technology, & Human Values, 39, 130–153. doi:10.1177/0162243913512538

31.

Meserole

R. L.

Carson

C. M.

Riley

A. W.

Wang

N.-Y.

Quittner

A. L.

Eisenberg

L. S.

. . . Niparko

J. K.

(2014). Assessment of health-related quality of life 6 years after childhood cochlear implantation. Quality of Life Research, 23, 719–731. doi:10.1007/s11136-013-0509-3

32.

Mitchell

R. E.

Karchmer

M. A.

(2004). Chasing the mythical ten percent: Parental hearing status of deaf and hard of hearing students in the United States. Sign Language Studies, 4, 138–163. doi:10.1353/sls.2004.0005

33.

Patrick

D. L.

Edwards

T. C.

Skalicky

A. M.

Schick

Topolski

T. D.

Kushalnagar

. . . Sie

(2011). Validation of a quality-of-life measure for deaf or hard of hearing youth. Otolaryngology-Head and Neck Surgery, 145, 137–145. doi:10.1177/0194599810397604

34.

Prawitz

A. D.

Garman

E. T.

Sorhaindo

O’Neill

Kim

Drentea

(2006). Incharge Financial Distress/Financial Well-Being Scale: Development, administration, and score interpretation. Financial Counseling and Planning, 17(1), 34–50.

35.

Pugh

K. C.

Crandell

C. C.

(2002). Hearing loss, hearing handicap, and functional health status between African American and Caucasian American seniors. Journal of American Academy of Audiology, 13, 493–502.

36.

Punch

Hyde

Creed

P. A.

(2004). Issues in the school-to-work transition of hard of hearing adolescents. American Annals of the Deaf, 149, 28–38.

37.

Ringdahl

Grimby

(2000). Severe-profound hearing impairment and health-related quality of life among post-lingual deafened Swedish adults. Scandinavian Audiology, 29, 266–275. doi:10.1080/010503900750022907

38.

Roland

Fischer

Tran

Rachakonda

Kallogjeri

Lieu

J. E. C.

(2016). Quality of life in children with hearing impairment: Systematic review and meta-analysis. Otolaryngology-Head and Neck Surgery, 155, 208–219. doi:10.1177/0194599816640485

39.

Ruffin

C. V.

Tyler

R. S.

Witt

S. A.

Dunn

C. C.

Gantz

B. J.

Rubinstein

J. T.

(2007). Long-term performance of Clarion 1.0 cochlear implant users. Laryngoscope, 117, 1183–1190. doi:10.1097/MLG.0b013e318058191a

40.

Santarelli

De Filippi

Genovese

Arslan

(2008). Cochlear implantation outcome in prelingually deafened young adults: A speech perception study. Audiology & Neurotology, 13, 257–265. doi:10.1159/000115435

41.

Schick

Skalicky

Edwards

Kushalnagar

Topolski

Patrick

(2012). School placement and perceived quality of life in youth who are deaf or hard of hearing. Journal of Deaf Studies and Deaf Education, 18, 47–61. doi:10.1093/deafed/ens039

42.

Smith

J. A.

(2011). Embracing the elephant in the room: Interviewing ideas for applicants who are deaf or hard of hearing. Journal of the American Deafness and Rehabilitation Association, 44(2), 67–81.

43.

Spencer

L. J.

Barker

Tomblin

J. B.

(2003). Exploring the language and literacy outcomes of pediatric cochlear implant users. Ear and Hearing, 24, 236–247. doi:10.1097/01.aud.000006923.72244.94

44.

Spencer

L. J.

Gantz

B. J.

Knutsen

(2004). Outcomes and achievement of students who grew up with access to cochlear implants. Laryngoscope, 114, 1576–1581. doi:10.1097/00005537-200409000-00014

45.

Stika

C. J.

(1997). Living with hearing loss—Focus group results, part II: Career development and work experiences. Hearing Loss, 18(6), 29–32.

46.

Stinson

Liu

(1999). Participation of deaf and hard-of-hearing students in classes with hearing students. Journal of Deaf Studies and Deaf Education, 4, 191–202. doi:10.1093/deafed/4.3.191

47.

Thoutenhoofd

E. D.

Archbold

S. M.

Gregory

Lutman

M. E.

Nikolopoulos

T. P.

Sach

T. H.

(2005). Pediatric cochlear implantation: Evaluating outcomes. Oxford, UK: Wiley Blackwell.

48.

Traxler

C. B.

(2000). The Stanford Achievement Test, 9th edition: National norming and performance standards for deaf and hard-of-hearing students. Journal of Deaf Studies and Deaf Education, 5, 337–339. doi:10.1093/deafed/5.4.337

49.

Tyler

R. S.

Parkinson

A. J.

Woodworth

G. G.

Lowder

M. W.

Gantz

B. J.

(1997). Performance over time of adult patients using Ineraid or Nucleus cochlear implant. The Journal of Acoustical Society in America, 102, 508–522. doi:10.1121/1.419724

50.

Uziel

A. S.

Sillon

Vieu

Artieres

Piron

J. P.

Daures

J. P.

Mondain

(2007). Ten-year follow-up of a consecutive series of children with multichannel cochlear implants. Otology & Neurotology, 28, 615–628. doi:10.1097/01.mao.0000281802.59444.02

51.

Vannson

James

Fraysse

Strelnikov

Barone

Deguine

Marx

(2015). Quality of life and auditory performance in adults with asymmetric hearing loss. Audiology & Neurotology, 20(Suppl. 1), 38–43. doi:10.1159/000380746

52.

Wagner

Newman

Cameto

Levine

Garza

(2006). An overview of findings from wave 2 of the National Longitudinal Transition Study–2 (Report No. NCSER 2006-3004). Retrieved from http://files.eric.ed.gov/fulltext/ED495660.pdf

53.

Wake

Hughes

E. K.

Collins

C. M.

Poulakis

(2004). Parent-reported health-related quality of life in children with congenital hearing loss: A population study. Ambulatory Pediatrics, 4, 411–417.

54.

Waltzman

S. B.

Cohen

N. L.

Green

Roland

J. T.

(2002). Long-term effects of cochlear implants in children. Otolaryngology-Head and Neck Surgery, 126, 505–511. doi:10.1067/mhn.2002.124472

55.

Weisel

Cinamon

R. G.

(2005). Hearing, deaf, and hard-of-hearing Israeli adolescents’ evaluations of deaf men and deaf women’s occupational competence. Journal of Deaf Studies and Deaf Education, 10, 376–389. doi:10.1093/deafed/eni045

56.

Winn

S. L.

(2007). Employment outcomes for the congenitally deaf in Australia: Has anything changed? American Annals of the Deaf, 152, 382–390. doi:10.1353/aad.2008.000

57.

World Health Organization Quality of Life Assessment Instrument Group. (1994). The development of the World Health Organization Quality of Life Assessment Instrument (WHOQOL). In Orley

Kuyken

(Eds.), Quality of life assessment: International perspectives (pp. 41–57). Berlin, Germany: Springer-Verlag.