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This article is published online with Open Access by IOS Press and distributed under the terms
Web-based auditory self-training system for adult and elderly users of hearing aids
Simone Virginia Vittia, Wanderléia Quinhoneiro Blascab, Daniel Sigulema, Ivan Torres Pisaa
a
Department of Health Informatics, Federal University of São Paulo (UNIFESP), São Paulo-SP, Brazil.
b
Department of Audiology, University of São Paulo (USP), Bauru-SP, Brazil
Abstract
INTRODUCTION. Adults and elderly users of hearing aids
suffer psychosocial reactions as a result of hearing loss.
Auditory rehabilitation is typically carried out with support
from a speech therapist, usually in a clinical center. For these
cases, there is a lack of computer-based self-training tools for
minimizing the psychosocial impact of hearing deficiency.
OBJECTIVE. To develop and evaluate a web-based auditory
self-training system for adult and elderly users of hearing
aids. METHODS. Two modules were developed for the web
system: an information module based on guidelines for using
hearing aids; and an auditory training module presenting a
sequence of training exercises for auditory abilities along the
lines of the auditory skill steps within auditory processing. We
built aweb system using PHP programming language and a
MySQL database .from requirements surveyed through focus
groups that were conducted by healthcare information
technology experts. The web system was evaluated by speech
therapists and hearing aid users. An initial sample of 150
patients at DSA/HRAC/USP was defined to apply the system
with the inclusion criteria that: the individuals should be over
the age of 25 years, presently have hearing impairment, be a
hearing aid user, have a computer and have internet
experience. They were divided into two groups: a control
group (G1) and an experimental group (G2). These patients
were evaluated clinically using the HHIE for adults and HHIA
for elderly people, before and after system implementation. A
third web group was formed with users who were invited
through social networks for their opinions on using the
system. A questionnaire evaluating hearing complaints was
given to all three groups. The study hypothesis considered that
G2 would present greater auditory perception, higher
satisfaction and fewer complaints than G1 after the auditory
training. It was expected that G3 would have fewer complaints
regarding use and acceptance of the system. RESULTS. The
web system, which was named SisTHA portal, was finalized,
rated by experts and hearing aid users and approved for use.
The system comprised auditory skills training along five lines:
discrimination; recognition; comprehension and temporal
sequencing; auditory closure; and cognitive-linguistic and
communication strategies. Users needed to undergo auditory
training over a minimum period of 1 month: 5 times a week
for 30 minutes a day. Comparisons were made between G1
and G2 and web system use by G3. CONCLUSION. The web
system developed was approved for release to hearing aid
users. It is expected that the self-training will help improve
effective use of hearing aids, thereby decreasing their
rejection.
Keywords:
Software (MeSH L01.224.900); Adult (MeSH M01.060.116);
Elderly (MeSH M01.060.116.100); Hearing Aids (MeSH
E07.814.458); Training (MeSH SP4.006.047.453.584); Reha-
bilitation (MeSH E02.831.800)
MEDINFO 2015: eHealth-enabled Health
© 2015 IMIA and IOS Press.
of the Creative Commons Attribution Non-Commercial License.
doi:10.3233/978-1-61499-564-7-168
Introduction
Sensorineural hearing loss is a chronic disease that can have
an impact on individuals’ daily lives¹. To minimize the day-to-
day impact of such a disease, there is a need for hearing aids
to be adapted for adults and elderly people with hearing loss.
This population often does not adapt well to using hearing aids
and these individuals often discard them. It has been
shown2,3,4 that auditory training helps users improve their dis-
crimination and comprehension of speech sounds. Simply
recalibrating the hearing aid does not help regarding users’
auditory quality. Specific auditory training techniques are
needed in order to positively influence the auditory processes
of neuronal plasticity in these individuals.
In Brazil, there is no web-based system aimed towards adult
and elderly users of hearing aids similar to the one proposed in
this study which exists. This system provides an original ap-
plication, and specific tools for auditory training, management
and analysis. Likewise, there are no references in the literature
relating to any system that addresses all of the skills relating to
the mechanism and processes of the auditory system: sound
detection, sound discrimination, auditory recognition, recogni-
tion of the temporal aspects of hearing and auditory perfor-
mance in relation to competing acoustic signals and in unfa-
vorable acoustic situations. This study is aimed to make it
possible to ascertain whether an intervention through infor-
mation technology (using a web-based system in the subject's
home) enables the improvement of the user's auditory skills
and adherence to hearing device use.
The objective of this study was to develop and evaluate a web-
based system for the auditory training of adult and elderly
users of hearing aids. This study formed part of the academic
activities of the Health 360 research group (Saúde 360,
saude360.com.br) a research group focused on consumer
healthcare information technology, clinical decision support
systems, e-health processes and evaluation, ontology for
healthcare, knowledge discovery, data mining and big data.
This group is part of the postgraduate program on Healthcare
Management and Information Technology, Federal University
of São Paulo (UNIFESP), Brazil.
Methods
The method used in this study was based on the construction
and evaluation of a web-based system for the auditory training
of adult and elderly users of hearing aids. This study was de-
veloped in the Department of Healthcare Information Tech-
nology, Paulista Medical School (EPM), UNIFESP, in part-
nership with the Department of Speech Therapy, University of
São Paulo, Bauru (FOB-USP). Data was gathered in partner-
ship with the Auditory Health Division (DSA) of the Cranio-
facial Abnormality Rehabilitation Hospital (HRAC-USP), in
 S.V. Vitti et al. / Web-Based Auditory Self-Training System for Adult and Elderly Users of Hearing Aids 169

Bauru. This study was approved by the Research Ethics Below is a diagram of the entity relationship model and data-
Committee of EPM-UNIFESP, under procedural number base management system (DBMS) of MySQL Server ® ver-
26949/2012, and the Research Ethics Committee of HRAC- sion 5.0, furnishing a conceptual description of the data
USP, under the number 569743/2014. that was used to construct the SisTHA portal database (Fig-
The web-based auditory training system has two modules: (1) ure 2):
an information module based on guidelines for using hearing
devices; and (2) an auditory training module based on differ-
ent lines of auditory skills. Both modules were developed in
PHP: Hypertext Preprocessor language (php.net). MySQL
DBMS version 5.0 (mysql.com) was used for data storage and
management.
The system was evaluated by five speech therapy specialists
and two individuals with hearing deficiencies who were hear-
ing aid users. They answered a questionnaire that evaluated
layout requirements, content and system usability. These re-
quirements were assessed based on a five level scale (very
poor, poor, fair, good and excellent). The top three levels (fair,
good and excellent) were considered to have indicated ap-
proval and that the two lowest levels rejection.
The population sample consisted of two groups of individuals
who were selected according to the following inclusion crite-
ria: age over 25 years; bilaterally symmetrical sensorineural Figure 2 – Entity relationship model (ERM) of the SisTHA
hearing loss of mild to moderate degree; new users who had portal database.
been bilaterally fitted with hearing aids featuring digital tech-
nology in accordance with the protocol of the Brazilian Na- Results and Discussion
tional Health System (SUS); literate; experience of web
browsing; and available to undergo auditory training lasting The web-based system at www.sistha.com.br was finalized
30 minutes a day for five days a week, over a four-week peri- with two modules:
od. Initially, 100 individuals were selected. They were sepa- 1) The information module had the aim of presenting
rated into a control group (G1) and an experimental group general information about auditory health and was
(G2). G1 did not have access to auditory training through the divided into two sections: hearing and hearing aids.
web-based system, while G2 had access to the auditory train- These sections were composed of the following sub-
ing module. A third experimental group named the web group sections: physiology of hearing; hearing loss; degree
(G3) was set up to assess system use and acceptance. G3 had of hearing loss; the hearing aid; hearing test; hearing
access to both modules of the SisTHA portal, but the inclusion care; communication strategy; questionnaire on hear-
criterion established for this group was that the questionnaires ing complaints; importance of hearing aid; types of
should be answered before and after the auditory training. All hearing aids; hearing aid and noise reduction; micro-
the subjects in the groups needed to give responses to the phone of the hearing aid; battery; how to put the
Hearing Handicap Inventory for the Elderly (HHIE) question- hearing aid on; mold and cleaning the hearing aid;
naire5 or the Hearing Handicap Inventory for Adults (HHIA) how to use a telephone or mobile phone with a hear-
questionnaire6 and a questionnaire on hearing complaints, be- ing aid. Figures 3, 4 and 5 shows the initial screens of
fore and after application of the research protocol. The three the system relating to the information module.
groups are described and the functionality and usability of the
web system are detailed below, in Figure 1. After the protocol
had been applied, the results were analyzed. The structure of
the method is shown below.

Figure 3 - Screenshot showing the initial page of the infor-

mation module.
(http://telemedicina6.unifesp.br/projeto/sistha).

Figure 1 – Structure method for the study

170 S.V. Vitti et al. / Web-Based Auditory Self-Training System for Adult and Elderly Users of Hearing Aids

• 130 sentences;
• 200 individual words;
• 30 sequences of words, in two equal categories;
• 50 sequences of two words of different categories
and lengths;
• 30 three-word sequences of equal categories;
• 50 sequences of three words of different categories
and length;
• Numbers from 0 to 10;
• 40 three-digit number sequences;
• 20 texts composed of 200 to 600 words;
• Audio of news and vignettes.

Figure 4 - Screenshot of information module relating to the
section on hearing aids and the subsection on types of hearing
aid.
(http://telemedicina6.unifesp.br/projeto/sistha/index.php?cap=
Aparelho%20Auditivo&tit=Tipos%20de%20aparelho%20aud
itivo)
Figure 5 – Screenshot of information module showing the sec-
tion on hearing aids and the subsection on degree of hearing
loss.
(http://telemedicina6.unifesp.br/projeto/sistha/index.php?cap
=Audi%C3%A7%C3%A3o&tit=Grau%20da%20perda%20a
uditiva)
The total amount of audio content produced for the content of
the SisTHA portal was 10,027. However, all of this content
was analyzed and selected. Through the analysis, 2,430 pieces
of audio content were selected using audibility and
intelligibility criteria. From these, some were selected to make
up the audio overlay, in accordance with the proposal for
auditory training through the SisTHA portal, for each line of
the auditory training.
Currently, the audio database contains a total of 5,345 selected
and finalized pieces of audio content.
The strategy of this module was to provide a sequence of
exercises on the computer screen, to assist hearing aid users
towards stimulating their hearing abilities. For this, the
auditory training was divided into five lines. Each line
corresponded to the stimulation of one of the mechanisms of
hearing skills: detection, discrimination, recognition,
comprehension and auditory memory.
Lines 1 to 4 of the auditory training presented three levels of
difficulty (level 1 easy, level 2 medium and level 3 hard),
while line 5, relating to communication strategy, had only one
level of difficulty. For each level, a specific number of
exercises were developed (Table 1), and were presented
randomly to users, within their current stage (line and level).

2) The auditory training module was constructed by Table 1– Number of exercises proposed within each line in the
searching for and producing images and audio material that web-based system.
were coherent with each other and presented similarities to the Total num-
day-to-day routines of the study population (in order to Stage ber of level 1 level 2 level 3
provide auditory training that would be as close as possible to exercises
the realities of the hearing aid user).
The auditory training was divided into five lines. Each of Line 1 120 40 40 40
these corresponded to the stimulus of one of the mechanisms Line 2 180 60 60 60
of the auditory skills of auditory processing: detection, Line 3 156 16 70 70
discrimination, recognition, comprehension and auditory
Line 4 104 20 44 40
memory.
Each image of the auditory training module was Line 5 15 15
correlated with corresponding audio material by means of the Continuous/
focus group method.7,8 In this, 10 subjects presenting with Line 6 Lines 1, 2, 3, 4, 5
random
normal hearing and vision assessed the images and audio
material separately and then correlated them. Both the images
The difficulty of the auditory training increases as users
and the audio material were selected only when there was a
correctly answers the exercises. When users give correct
unanimous agreement within the focus group. The SisTHA
answers for 60% of the proposed exercises at each level, they
portal presents 208 images in its database.
move to the exercises at the subsequent level. After one line
Audio recordings of voices were produced using the
has been completed, users change stage, and so on. However,
Audacity software. Recordings from twelve people were used
if they give wrong answers, the next exercise will remain at
(five men, five women and two children - a girl and a boy),
the level of difficulty of the previous exercise (which will be
with various accents and ages ranging from 9 years to 71
drawn within the same line and level). A running total of the
years. Each person was recorded while reading out numbers,
number of correct answers is kept, with the aim of avoiding
words, sentences and text, which were all prepared in
user frustration. It should be noted that the web-based system
accordance with the daily lives of the adult and elderly
is dynamic and that exercises can be added at any time that is
subjects. The summary statistics for recorded material are
convenient.
listed below:
 S.V. Vitti et al. / Web-Based Auditory Self-Training System for Adult and Elderly Users of Hearing Aids
Figures 6, 7, 8 and 9 present the screens of the SisTHA portal
with examples of exercises within different lines and at
different levels.
Figure 6 - Screenshot of the SisTHA portal referring to an
example of an exercise within line 1 at level 1. By clicking on
the "play" button, audio content is presented to the user, who
has to choose the correct image associated with the audio.
Figure 7 - Screenshot of the SisTHA portal referring to an
example of an exercise within line 1 at level 2. By clicking on
the "play" button, audio content is presented to the user, who
has to choose the correct image associated with the audio: the
voice of a man, woman or child.
Figure 8 - Screenshot of the SisTHA portal referring to an
example of an exercise within line 3 at level 3. By clicking on
the "play" button, audio content is presented to the user, who
has to choose the correct image associated with the audio,
with regard to comprehension and auditory memory.
171
Figure 9 - Screenshot of the SisTHA portal referring to an
example of an exercise within line 2 at level 1. By clicking on
the "play" button, audio content is presented to the user, who
has to choose the correct image associated with the audio.
As described earlier, the SisTHA portal was assessed by five
volunteer specialist speech therapists with between 15 to 28
years of professional experience in the field of auditory
rehabilitation. These professionals had academic qualifications
as specialists in speech therapy, alongside their master's and
doctoral degrees. They were working in universities and
consultation offices. Evaluation of the system was also
performed by two volunteer hearing aid users with bilateral
hearing loss and a minimum of 25 years of hearing aid use.
This evaluation consisted of a questionnaire which assessed
the layout, content and usability requirements of the system.
Responses were coded via a five-level scale (very poor, poor,
fair, good and excellent). The top three levels (fair, good and
excellent) indicated approval and that the two lowest levels
indicated rejection. Responses to the questionnaires evaluating
the system were analyzed by using descriptive statistics and
content analysis from the perspective of Bardin.9
From the point of view of the speech therapists, the
information module was approved with regard to the access
requirements, layout, content, images, audio content and
videos. The auditory training module was approved with
regard to access, layout, volume adjustment, images, audio
content and coherence between image and audio. Regarding
the impact of the web-based system for hearing aid users, all
the experts stated that the expected impact was positive. The
evaluators reported that the following were important
suggestions for the web system: improvement of the
presentation of images, given the delays in loading them;
insertion of a screen at changes in line regarding the number
of correct answers per level; insertion of an incentive screen;
and provision of access to screening of auditory processing
before and after the auditory training to ascertain whether
there was any improvement in the user’s hearing abilities.
Regarding the evaluation of the web system by hearing aid
users, both modules (information and auditory training) were
approved in relation to all of their requirements. The hearing
aid users provided a suggestion for the web system that an
alternative should be included in the exercises such that users
could choose not to answer the question (this option is already
included in the current version). In addition, it was suggested
that both a screen showing the number of correct answers per
line and per level and a screen showing the change in line
should be inserted.
Currently, the web-based system is at the data-gathering phase
with the control, experimental and web groups until May
2015. Management and analysis of results will be carried out
in June 2015.
172 S.V. Vitti et al. / Web-Based Auditory Self-Training System for Adult and Elderly Users of Hearing Aids
Conclusion
A web-based system for helping in training the auditory skills
of hearing aid users was constructed and evaluated for clinical
use. In future clinical trials using the control, experimental and
web groups, it is expected to be possible to assess whether
standardized training done at home enables effective use of
hearing aids, thereby giving rise to the possibility of reducing
their rejection.
Acknowledgement
To FAPESP for assistance through the doctoral scholarship
granted (number 2012 / 05410-0); to CNPQ for its Universal
Notice with procedural number 4809 / 2011-8 in the name of
Prof. Dr. Wanderléia Q. Blasca; and to the Auditory Health
Division of HRAC-USP and the Department of Health
Informatics, EPM-UNIFESP, for support and encouragement
in the development of this study. We especially thank the
speech therapists and hearing aid users who contributed to this
study.
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Address for correspondence
Simone Virginia Vitti, Postgraduate Program on Health
Informatics, Department of Health Informatics, Federal
University of São Paulo, Rua Botucatu 862, Edifício Leal
Prado, térreo, São Paulo, Brazil.
Telephone: +551155764347
Cell phone: +5512981165569
E-mail: simone.vitti@gmail.com