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European Annals of Otorhinolaryngology, Head and Neck diseases 133S (2016) S25–S30

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Original article

Hearing-related quality of life outcomes for Singaporean children


using hearing aids or cochlear implants
V. Looi a,∗ , Z.Z. Lee b , J.H.Y. Loo b
a
SCIC Cochlear Implant Program, an RIDBC Service, The Australian Hearing Hub, Ground Floor, 16, University Avenue, 2109 Sydney, Australia
b
Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

a r t i c l e i n f o a b s t r a c t

Keywords: Objectives: The Children Using Hearing Devices Quality of Life Questionnaire (CuHDQOL) is a new parent-
Quality of life administered hearing-specific questionnaire for children fitted with hearing devices. The aim of this study
Cochlear implants was to assess outcomes for hearing-impaired children in Singapore using this measure, as well as to
Hearing aids
examine its applicability for use in a clinical setting.
Hearing-impaired
Materials and methods: The CuHDQOL has 26 items, uses a recall period of 1 month, and is divided into
Outcomes
three sections: parental perspectives and expectations (eight items), impact on the family (eight items)
and hearing-related quality of life (QOL) of the child (10 items). Responses are made on a 5-point Likert
scale, and transformed to a score from 0–100. Twenty-two parents of children with hearing aids and 14
parents of children with cochlear implants completed the CuHDQOL.
Results: The mean total CuHDQOL scores was 62/100 for the children using hearing aids and 53/100
for children with cochlear implants. Scores for the children using hearing aids were higher across all
subscales, with a linear regression showing this to be significant for the parental perspectives and expec-
tations subscale (B = −10.58, P = 0.041). Analyses of Variance showed that both the ‘Parent Perspective
and Expectations’ and the ‘Hearing-related QOL’ subscales were significantly higher than the ‘Impact on
Family’ subscale for both groups (P ≤ 0.003).
Conclusions: The CuHDQOL was found to be a simple, efficient questionnaire that could easily be incorpo-
rated into clinical practice to provide a more holistic evaluation of a child’s outcomes post intervention,
and/or to monitor their progress over time.
© 2016 Elsevier Masson SAS. All rights reserved.

1. Introduction Quality of life is a subjective evaluation and is impacted on by


cultural, social, and environmental factors [1]. It is defined by the
In Singapore, traditional outcome measures used to assess and World Health Organisation (WHO) as an “Individuals’ perceptions
monitor progress with hearing devices have included puretone of their position in life in the context of the culture and value sys-
audiometry and speech audiometry. However there has been a tems in which they live and in relation to their goals, expectations,
strong push in more recent times to evaluate functional, ‘real world’ standards and concerns” [1] (p. 551). The International Classifica-
benefits of intervention using quality of life (QOL) measures. It is tion of Functioning, Disability and Health (ICF) was developed by
well accepted that hearing not only impacts on speech and lan- the WHO to enable uniform assessment of the impact of a health
guage development, which are traditionally assessed at a clinical condition (such as hearing loss) on the lifestyle of the individual and
level using validated speech and language assessments, but also on those close to them [2]. The ICF is a theoretical model acknowledg-
self-esteem, emotional, social and psycho-social development as ing that an impairment such as hearing loss is not just limited to the
well as educational and vocational outcomes. It is these areas that actual body structure/function (e.g. the hearing mechanism itself),
are not routinely evaluated through traditional clinical audiology but also impacts on the individual at a wider, psycho-social level.
or speech and language tests, hence the value of QOL measures. Hence, the experience of an individual with an impairment such as
hearing loss will differ due to differences in the nature and severity
of their loss, personalities, and psychological factors such as coping
skills, and environmental considerations.
∗ Corresponding author. Quality of life can be assessed using either generic or
E-mail address: Valerie.looi@scic.org.au (V. Looi). condition-specific instruments. The former assesses overall health

http://dx.doi.org/10.1016/j.anorl.2016.01.011
1879-7296/© 2016 Elsevier Masson SAS. All rights reserved.
S26 V. Looi et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133S (2016) S25–S30

and well-being, and can be administered with different health responses (0 = strongly disagree, 1 = disagree, 2 = unsure, 3 = agree,
conditions and/or ‘normal’ populations. Condition-specific (or and 4 = strongly agree, with a ‘not applicable’ option being avail-
disease-specific) instruments were designed for application to a able), which are transformed to a score from 0 to 100 for statistical
certain group with a particular condition. Generic measures can analyses. Negatively-voiced questions are reverse scored so that a
lack the sensitivity and specificity to identify changes in a person’s higher score always indicates a more positive response.
QOL which are specific to a particular condition or intervention.
For example, hearing-specific instruments can help to monitor and 2.2.2. Demographic form
detect clinically relevant changes due to the hearing loss and/or A separate form was developed to collect study-specific
hearing intervention. information such as demographic, socio-economic, school and
At present, there are very few hearing-specific QOL measures for hearing-specific details. Information collected included the par-
children in the clinical setting, and particularly for children using ents’ highest education level, parental employment status, and
cochlear implant(s) (CIs). This combined with the fact that current income, in addition to child-specific details such as their age, race,
paediatric hearing outcome measures used in Singapore are pre- birth order, main language spoken at home, main caregiver, and
dominantly functional measures of hearing thresholds, speech and family composition. School-related information obtained included
auditory skills led to this study. The aim of this study was to utilise school level (or grade), main language used in school, type of school
a new pediatric hearing-specific QOL measure to assess the QOL (e.g. mainstream school), age appropriateness of school level,
outcomes for hearing-impaired children in Singapore, as well as to and general academic performance (e.g. average). Hearing-related
examine the applicability of this questionnaire for use in a clinical information included type of hearing habilitation (e.g. auditory-
setting. This is one of the first studies administering the CuHDQOL, verbal therapy), main communication mode, amount of device use
and the first study in Singapore to investigate pediatric hearing QOL per day, use of assistive listening devices (ALDs) at school. Other
for children using hearing aids (HAs) or CIs. audiological information such as the aetiology, onset, degree and
laterality of loss, type of hearing device(s) fitted, duration of impair-
2. Materials and methods ment, and hearing age were extracted from the child’s clinical
audiology files. This information is presented in Table 1.
This study was part of a larger study, details of which are avail-
able in Looi et al. [3]. This paper focuses on the hearing-specific 2.3. Procedures
QOL outcomes from that study. Ethics approval was obtained from
the National Healthcare Group’s Domain Specific Review Board in Parents completed hard-copies of the questionnaires in a quiet,
Singapore. otherwise unoccupied room. They were free to clarify any questions
at the time, and average completion time was less than 10 minutes.
2.1. Participants
3. Results
Twenty-two parents of children with HAs and 14 parents of chil-
Mean scores out of 100 for each question for the HA and CI
dren with CIs were involved. Children that were bimodally fitted
groups, along with the subscale summary scores and the mean
were classified under the CI group. The inclusion criteria were that
total score, is provided in Table 2. Linear regression showed that
the participants were parents of hearing-impaired children aged
the mean total score for the HA group of 62.07 (SD 12.30) was
2–18 years who were born and raised in Singapore. The children had
significantly higher than the CI group’s score of 52.99 (SD 11.76)
to have worn HAs and/or CIs for at least six months, and parents had
(B = −9.1, P = 0.035). The subscale scores were as follows: parent
to have sufficient command of English to interpret and complete the
perspectives and expectations – CI: 56.92 (SD 12.15), HA: 67.49
questionnaire independently. Parents were excluded if their child
(SD 15.92); impact on family – CI: 38.39 (SD 16.78), HA: 46.19 (SD
had been diagnosed with a significant physical, cognitive and/or
17.53), child QOL–CI: 62.40 (SD 11.91), HA: 70.68 (SD 13.34). In
developmental delay, had a significant learning and/or behavioural
comparing the subscales’ scores, linear regressions showed that the
disorder, or had been diagnosed with a significant of major acute
CI group reported significantly lower scores for the ‘Parental per-
medical condition. All children were receiving audiological care at
spectives and expectations’ subscale (B = −10.58, P = 0.041, < 0.05)
the time of the study, and their hearing device was worn at the
than the HA group, with no significant differences for the ‘Impact
settings prescribed by the audiologist. Further information on the
on family’ or ‘Child hearing-related QOL’ subscales. A one-way
children is presented in Table 1.
analysis of variance (ANOVA) with Boneferroni corrections for the
CI group showed that both the ‘Parent perspective and expecta-
2.2. Materials tions’, along with the ‘Child hearing-related QOL’ subscales were
significantly higher than the ‘Impact on family’ subscale (P = 0.003
2.2.1. Children using Hearing Devices Quality of Life (CuHDQOL) and P < 0.001, respectively). The same results were found for the
Questionnaire HA group (P < 0.001 for both comparisons). There was no dif-
The CuHDQOL questionnaire is a new parent-administered ference between the ‘Parent perspective and expectations’ and
hearing-specific QOL questionnaire, developed specifically for chil- the ‘Child hearing-related QOL’ subscales for either the CI or HA
dren fitted with hearing devices [4]. The 26–item CuHDQOL group.
questionnaire uses a recall period of 1 month, and is divided into In examining the responses for the individual questions, it
three subsections: would appear that parenting a child with a hearing impairment
is demanding on their time. Both the HA and CI groups provided
• parental perspectives and expectations (eight items); comparatively lower scores (when compared to most of the other
• impact on the family (eight items) and; questions) for question 4 (“my child needs more of my daily
• hearing-related QOL of the child (10 items) attention than other typically developing children their own age”)
as well as question 11 (“I devote more time to my child than
It covers six domains: self-reliance, well-being and happiness, other members of my family”). For the CI group, other areas which
social functioning, general functioning, parental stress and family were concerns for parents were predominantly in the ‘impact
cohesion [4]. A 5-point Likert scale is used to record participants’ on family’ subsection, including whether the hearing device was
V. Looi et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133S (2016) S25–S30 S27

Table 1
Participant details.

HA CI

M SD Range M SD Range

Age at assessment (years) 10.2 4.4 3–17.8 8.0 4.4 2.2–17.3


Age first diagnosed with hearing loss (months) 54.3 47.9 6–180 26.4 31.5 6–108
Age of first HA fitting (months)b 66.3 47.4 8–192 39.6 31.8 9–110
Age of first CI fitting (months) N.A. 62.5 60.0 16–198
Duration of hearing-impairment (months) 12.0 13.9 1–48 13.2 13.1 1–36
Experience with CI (months)d N.A. 34.2 32.0 6–100
Experience with HA (months)c 55.8 40.0 10–126 43.8 46.1 3–171

n % n %

Laterality of hearing loss


Unilateral 3.0 13.6 – –
Bilateral symmetrical 16.0 72.8 8.0 57.1
Bilateral asymmetrical 3.0 13.6 6.0 42.9
Laterality of hearing device fitting
Unilateral 3.0 13.6 – –
Bilateral 19.0 86.4 5.0 35.7
Bimodal – – 9.0 64.3
Aetiology
Congenital 4 18.2 1 7.1
Syndromic – – 3 21.5
Ototoxicity 2 9.1 1 7.1
Unknown 16 72.7 9 64.3
Degree of hearing loss (right ear)a
Mild 3 13.6 – –
Moderate 8 36.4 – –
Severe 9 40.9 3 21.4
Profound 1 4.5 11 78.6
N.A. 1 4.5 – –
Degree of hearing loss (left ear)b
Mild 1 4.5 – –
Moderate 10 45.5 – –
Severe 9 40.9 6 42.9
Profound – 4.5 8 57.1
N.A. 2 4.5 – –
Main communication mode
Spoken 21.0 95.5 10.0 71.4
Sign 0.0 0.0 1.0 7.1
Spoken and sign 1.0 4.5 3.0 21.4
Received hearing rehab in 1st year of fitting
Yes (weekly) 15.0 68.2 14.0 100.0
Yes (monthly) 1.0 4.5 – –
No 6.0 27.3 – –
Hearing rehab received
Auditory–verbal therapy 15.0 68.2 13.0 92.9
Mixed/total communication 1.0 4.5 1.0 7.1
Sign language – – – –
N.A. 6.0 27.3 – –
Device worn daily
Yes 17.0 77.3 13.0 92.9
No 5.0 22.7 1.0 7.1
Duration worn per day
Never 1.0 4.5 – –
< 2 hours 2.0 9.1 1.0 7.1
2–6 hours 4.0 18.2 – –
> 6–12 hours 10.0 45.5 5.0 35.7
> 12 hours 5.0 22.7 8 57.1
ALD usage at school
Yes 11.0 50 9 64.3
No 11.0 50 5 35.7
a
Degree of hearing is calculated based on the unaided pure tone average (PTA) at 0.5 kHz, 1 kHz, 2 kHz, and 4 kHz of the child’s most recent hearing levels.
b
Note: all CI children implanted at this clinic were required to undergo an HA trial for at least 3 months, prior to receiving their CI.
c
For bimodally fitted children, ‘Experience with HA’ refers to the duration between the date of first HA fitting to the date of questionnaire completion. For bilaterally fitted
CI children, ‘Experience with HA’ refers to the duration between the date of first HA fitting to the date they were implanted.
d
‘Experience with CI’ refers to the duration between the date of first implantation to the date of questionnaire completion.

functioning correctly, educational outcomes, and both financial needs (question 17). Interestingly, although both groups rated
and familial stress. For children using HAs, financial stress and that they were concerned about their child’s future educational
educational outcomes were also primary areas of concern to placement and achievement (question 14), both groups also
parents. On the positive side, enjoyment of music was highly rated strongly believed that their child would have greater educa-
by both HA and CI parents (question 24) as was their ratings of tional opportunities and achievement with their hearing device
their child’s ability to use spoken language to communicate their (question 3).
S28 V. Looi et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133S (2016) S25–S30

Table 2
Mean scores from each question of the CuHDQOL for the HA and CI groups.

HA CI

Section 1 – parent perspectives & expectations 67.49 (15.92) 56.92 (12.15)


1 My child easily makes friends with other children 72.73 (24.29) 57.14 (24.86)
2 My child’s spoken language is similar to typically developing children their 60.23 (29.54) 48.08 (31.39)
own age
3 I believe my child will have greater educational opportunities and 72.91 (21.07) 80.36 (14.47)
achievements with their hearing device
4 My child needs more of my daily attention than other (typically developing) 34.09 (28.40) 23.21 (24.93)
children their own age
5 I believe that as an adult my child will be able to find employment and 76.14 (22.46) 64.29 (16.16)
support themselves
6 I believe my child will lead a happy life 78.41 (19.36) 67.86 (15.28)
7 I believe my child will feel safe in the world 73.86 (24.97) 60.71 (21.29)
8 I believe my child will feel confident in the world 71.59 (22.22) 53.57 (16.57)
Section 2 – Impact on family 46.19 (17.53) 38.39 (16.78)
9 I always worry about whether the hearing device/s is/are working correctly 46.59 (33.00) 21.43 (21.61)
10 Our financial situation is stressed by the ongoing costs to maintain the 30.68 (29.81) 33.93 (28.77)
hearing device/s (e.g. spare parts, batteries, travel to appointments, etc.)
11 I devote more time to my child than other members of my family 27.27 (23.03) 32.14 (34.57)
12 Our immediate family’s activities are limited by our child’s hearing needs 61.36 (32.48) 64.29 (27.24)
13 The hearing device/s has/have improved communication between my 60.71 (29.12) 69.64 (35.60)
immediate family members
14 The future educational placement and achievement for my child is a concern 38.64 (37.58) 23.21 (31.72)
for our immediate family
15 We have had to change our working patterns since our child received their 55.68 (32.67) 32.14 (38.52)
hearing device(s)
16 My child’s hearing needs place additional stress on our immediate family 48.86 (35.75) 30.36 (31.28)
Section 3 – Hearing-related quality of life of your child 70.68 (13.34) 62.40 (11.91)
17 My child is able to communicate their needs using spoken language 72.73 (31.73) 76.79 (30.17)
18 My child is confident in social situations with typically developing children 76.14 (18.06) 48.21 (30.17)
their own age
19 My child initiates conversations with other children and adults 71.59 (19.36) 61.54 (28.17)
20 My child’s speech is clear and can be understood by people who have not 59.09 (28.40) 46.15 (26.70)
met them before
21 My child is often ill and asks to stay home from school 73.86 (27.25) 93.75 (11.31)
22 My child overhears conversation that is not directed at them and asks 68.18 (24.62) 38.46 (37.66)
questions about what was said
23 My child keeps up with their peers for daily learning activities at 64.77 (26.34) 48.33 (28.39)
pre-school/kindergarten/school
24 My child enjoys music 86.36 (22.79) 82.69 (18.78)
25 My child tires more easily than other typically developing children their 69.32 (31.75) 73.21 (28.53)
own age
26 My child is often afraid of new situations 64.77 (30.53) 57.14 (28.47)
Total CuHDQOL 62.07 (12.30) 52.99 (11.76)

Mean score/100; (SD in parentheses).

4. Discussion when compared to parents of healthy children, but lower levels


of psychological distress than parents of children in poor, ailing
The mean total CuHDQOL scores in this study was 62/100 for the health. The increased time required to parent a child with a hear-
children using HAs and 53/100 for children with CIs. As there are ing impairment was the most noticeable impact that hearing loss
currently no publications reporting mean scores for the CuHDQOL had on the QOL of this parent cohort. In addition to coping with
with different target populations, it is not possible for the authors the initial diagnosis, parents must then acquire a substantial and
to categorise these scores in terms of the relative level of QOL (e.g. complex body of knowledge to decide on how their child should
whether these scores indicate a ‘good’, ‘satisfactory’, or ‘poor’ QOL). be treated and cared for [5,6]. Then once their child’s device is fit-
However as more clinics adopt this new measure and subsequently ted/implanted, they are then responsible for ensuring that their
publish their findings, we will obtain a more meaningful under- child wears the device, maintenance, as well as attending clinical
standing for the interpretation of these mean scores. The ‘Child appointments. This is in addition to all of their other work and fam-
hearing-related QOL’ subscale was the highest rated subsection for ily responsibilities, and the needs of their other children or family
both groups, with the ‘Impact on the family’ being the lowest rated. members.
Again, due to the paucity of publications using this measure, it is On the positive side, greater educational opportunities, enjoy-
not yet known how this subsection ordering would compare to ment of music, and communication of needs using spoken language
a different population sample, or in a different context (e.g. dif- were three of the higher scoring questions for both groups. This
ferent country, different age group, different target population, would imply that parents felt that the hearing device should pro-
etc.). Parenting a child with a hearing loss (or any other kind of vide better long term education-related outcomes for their child,
additional needs) places additional stress on the parent and the and that the device has enabled their child to communicate with
family. It can make some of the common parenting demands more spoken language. The high ratings for music enjoyment is consis-
challenging, as well as create new demands. Spahn et al. [5] used tent with current research from CI users which suggests that whilst
the term ‘psychological distress’, and found that parents of chil- many postlingually deafened adult recipients do not enjoy music
dren with CIs showed heightened levels of psychological distress with their implant, children who learnt to hear with their implant
V. Looi et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133S (2016) S25–S30 S29

love music, and actively participate in different kinds of musical 4.1. Clinical recommendations
activities [7].
The overall finding that the CuHDQOL scores were higher from A secondary purpose of this paper was to provide preliminary
parents of children with HAs than for parents of children with CIs is results for the new CuHDQOL questionnaire [4] and examine its
most likely explained by the former group of children having bet- clinical applicability. There are very few pediatric-specific ques-
ter hearing thresholds than the CI children. This is somewhat in tionnaires that evaluate hearing QOL outcomes, and as yet there are
keeping with a retrospective study conducted by Spahn et al. [8] currently no other published outcome studies that have used this
who evaluated the expectations of parents before and after their measure. Further, this is the first time data on hearing-specific QOL
child had been fitted with HAs or CIs using a ‘treatment expecta- outcomes for Singaporean children with hearing loss published.
tions’ questionnaire. There were 154 HA parents and 103 CI parents, The authors found the CuHDQOL efficient to administer and eas-
with the mean age of the children being 6.8 years for those using ily understood by parents. Taking less than 10 minutes to complete
HAs and 7.0 years for those using CIs (range: 2 to 16 years). The using a 5-point Likert scale, it could be adopted in a clinical set-
questionnaire assessed expectations in the following areas: ting by giving it to the parent/caregiver to complete whilst their
child was being tested. This would enable clinics to obtain a more
• general; holistic view of the child’s progress and real-life function, provide
• hearing through their device; more patient-specific information to aid counselling and clinical
• ability to cope in mainstream schools, and; care, potentially help to identify and/or explain disparities or con-
• comprehension of normal speech. cerns (e.g. if clinical speech perception test scores do not reflect
the comments from parents or the child), as well as provide infor-
Findings showed that before the child was fitted/implanted, the mation as to whether the intervention may also indirectly help
HA parents had higher expectations mean scores compared to the the parents and family. Although this current study only admin-
CI parents on all the domains measured. After their child had been istered the CuHDQOL once in a cross-sectional study design, the
fitted/implanted, the HA parents scored higher than the CI par- authors would recommend that the measure be administered pre-
ents in all domains except for ‘general expectations’. When the device fitting, and then at consistent time points post-fitting (e.g.
mean ‘general expectations’ scores were compared pre- to post- 3 months, 6 months, 12 months, 24 months, etc.) to monitor the
implantation for the CI parents, scores were significantly higher child’s progress. In addition, as suggested by Looi et al. [3], includ-
scores post-implantation (P < 0.05). One limitation of the study was ing a general health QOL measure to this hearing-specific measure
that no statistical analyses were conducted to compare the CI to to clinical protocols would provide a more complete picture for the
HA groups, nor any information provided on the timing for the clinician, as significant moderate correlations were found between
administration of the questionnaire (i.e. how many months pre- general health QOL and hearing-specific QOL.
and post-implantation/fitting) [8].
In contrast, Cohen et al. [9] compared QOL ratings from 54 5. Conclusions
adult HA users to 27 adult CI recipients. Whilst both HAs and
CIs improved QOL when ratings were compared pre- to post- This paper reported on the hearing-specific QOL outcomes for
intervention (P = 0.001), the change was greater for CI recipients; 36 hearing-impaired Singaporean children – 22 with HAs, 14 with
they had twice as much improvement in their overall QOL scores CIs, collected by administering the new CuHDQOL questionnaire
(P = 0.003), with the most difference noted for the basic sound per- [4]. Scores for the HA children were higher than for the CI children
ception category, where the benefit was almost three times that of across all subscales, however the HA children had better hearing
the HA users (P < 0.001). Again, level of hearing loss would be the thresholds than the CI users. The increased time and attention that
primary reason for this finding, as those with a CI had a profound parents felt they expended in caring for a child with a hearing loss
hearing loss prior to intervention and would probably have experi- was the area that was most negatively rated by parents in this study,
enced a greater impact of their intervention than those with lesser with ‘Impact on family’ being the lowest scoring subsection for both
levels of hearing loss. groups. However, on the positive side, parents felt that the hear-
As mentioned in the methods, this paper was part of a larger ing device provide greater educational opportunities for their child,
study on QOL outcomes for hearing-impaired children in Singa- that their child was well able to communicate their needs using
pore [3]. As part of that study, and as reported by Looi et al. spoken language, and enjoyed music. The CuHDQOL was found
[3], correlations between participant variables and the CuHDQOL to be a simple, efficient questionnaire providing hearing-specific
scores were examined. The stepwise regression showed that of QOL for children that clinicians could easily incorporate into their
five factors entered into the initial model (child’s age at first fit- clinical practice to provide a more holistic evaluation of a child’s
ting, duration of hearing-impairment prior to first fitting, hearing outcomes post intervention, and/or to monitor their progress over
device configuration, maternal education and family household time.
income), only family household income (P = 0.015) was a significant
predictor of the CuHDQOL scores accounting for approximately
16.2% (R2 = 0.162) of the variance of the CuHDQOL scores. This Disclosure of interest
matches the scores from question 10 of the CuHDQOL (“our finan-
cial situation is stressed by the ongoing costs to maintain the The authors declare that they have no competing interest.
hearing device/s”) where the mean score from the HA parents
was 30.68/100, and 33.93/100 for the CI parents. Neither mater- Acknowledgment
nal education nor hearing device configuration were statistically
significant predictors. Independent samples t-tests showed that The authors would like to thank Dr Alex Cook and Ms Chloe
for the HA group, there was no significant difference in the total He for statistical advice, the Mapi Research Trust for permission to
CuHDQOL score between unilaterally and bilaterally fitted children, use the PedsQL measures, the staff at the Audiology Department of
probably due to the small number of unilaterally fitted children the National University Hospital Singapore for help with recruit-
(n = 22, 3 unilateral, 19 bilateral). For the CI group, there was also no ment, Georgina Sanderson from Cochlear Ltd. for permission to use
significant difference in the total CuHDQOL between the bilaterally the CuHDQOL questionnaire, and the children and families who
and bimodally fitted children (n = 14, 5 bilateral, 9 bimodal). participated in this study.
S30 V. Looi et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133S (2016) S25–S30

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