Equus caballus) herd in Cape Toi, Japan, were investigated in terms of kinship, grooming, aggression, proximity, social rank, and social network. The correlations between mutual grooming and proximity and between aggression and proximity were established mathematically. Controlling for kinship, there were significant positive partial correlations between mutual grooming and proximity and between aggression and proximity. No correlation was observed between aggression and mutual grooming. Individuals that spent less time on self-grooming invested longer times receiving grooming from other individuals. In a feral horse population, mutual grooming maintains hygiene by controlling ectoparasites and forges affiliative interactions between herd members.Social grooming strengthens affiliative relationships between participants in many social primates. Three hypotheses regarding the function of mutual grooming in feral horses were tested: the affiliative relationship strengthening hypothesis, the worsened relationship restoring hypothesis, and the parasite removal hypothesis. All the nine horses in the “6m” herd in a Misaki feral horse  herd in Cape Toi, Japan. All the nine horses in the “6m” herd were investigated in terms of kinship, grooming, aggression, proximity, social rank, and social network. Mutual grooming occurred only in pairs and was almost perfectly symmetrical. For each member, there was a significant negative correlation between total grooming received from other individuals and self-grooming. Controlling for kinship, there were significant positive partial correlations between mutual grooming and proximity and between aggression and proximity. No correlation was observed between aggression and mutual grooming. The results suggest that mutual grooming symmetry may contribute that both participants simultaneously benefit from parasite removal and strengthen affiliative relationships between seasonally changing herd members; however, mutual grooming did not foster restoring the worsened relationship following aggression promoted by physical proximity. The findings of this study may elucidate the mechanisms by which interactions between herd members are maintained or strengthened.Although herd size, structure, stability, and social rank among Misaki feral horses have been reported, no studies have been conducted on the affiliative relationships and interactions among members in a Misaki horse herd. The validity of three hypotheses regarding the function of social grooming, the affiliative relationship strengthening hypothesis, the worsened relationship restoring hypothesis, and the grooming parasite removal hypothesis, were tested in a Misaki feral horse ( In many mammals, individuals strengthen affiliative relationships with unrelated individuals to enhance their reproductive success ,2,3. SocEquus caballus) that have left human control and live in environments with minimal artificial control are known as feral [Horses  and mutual grooming  ,30,31. SAffiliative relationships between pairs of horses may be indicated by the frequency of their close interactions ,33,35. KAnother hypothesis proposes that mutual grooming restores worsened relationships when aggressive interactions occur in pairs . Thus, aAggressive interactions may be byproducts of the physical proximity between individuals of different social rank ,42. In tGrooming is considered a maintenance behavior in horses. It removes ectoparasites such as lice and flies . The groThe objective of the study was to clarify the role of mutual grooming within the feral herd by testing the aforementioned predictions derived from three hypotheses regarding the function of mutual grooming; the affiliative relationship strengthening hypothesis, the worsened relationship restoring hypothesis, and the grooming parasite removal hypothesis.Misaki feral horses live in a protected ~550 ha area at Cape Toi, Kushima City, Miyazaki Prefecture, Japan ,22,43. TAs of 2018, there are 120 extant Misaki feral horses. They inhabit Komatsugaoka and Ogiyama, located at altitudes of 287 m and 296 m, respectively, situated near the center of Cape Toi, Kushima City, Miyazaki Prefecture, Japan. The aforementioned regions have the largest total grassland area within the cape and constitute the main home range of Misaki feral horses . The MisOne of the herds (the “6m” group) uses Komatsugaoka as their home range. All the nine members of the “6m” group were targeted for this survey . During The study was conducted during breeding season and the beginning of the non-breeding season of the Misaki feral horse ,43. The The kinship of the paternal lineage of Misaki feral horses is unknown. However, the maternal lineage was elucidated through birth records. The relatedness (r) among the members of the “6m” group was assumed to be 0.5 for individuals in mother-child relationships, and 0.25 for individuals in sibling relationships sharing a mother. The relatedness between individuals without a directly confirmed kinship was assigned to 0. A kinship matrix was constructed wherein the relatedness between pairs was used as each element.The Misaki feral horses were highly aggregated during the study period ,43,46. Ni grooms individual j but not vice-versa, the symmetrical state wherein both i and j are grooming each other simultaneously, and the pausing state defined as an interruption in grooming that is resumed within 120 s. If mutual grooming was resumed >120 s after the interruption, it was defined as an independent bout. For each individual, the total amount of grooming received from other individuals during mutual grooming was reported as the sum of the asymmetrical and symmetrical states. A grooming matrix was constructed using the number of observed mutual grooming bouts throughout the study period in all pairs as elements.For both self- and mutual grooming, the start and end times and the individual who started and ended the behavior were recorded. The total time spent self-grooming by each individual was calculated in seconds from these data. Mutual grooming is expressed in terms of the asymmetrical state wherein individual In aggressive interactions, an individual threatens or attacks another individual and/or the threatened or attacked individual retreats, flees, or avoids ,30,36. Ti) of individual i was calculated according to Equation (1) and each s(i) was corrected according to Equation (2) to obtain s′(i). Individuals with a larger s’(i) were regarded as higher-ranked:iW is the total number of aggressive interactions won by individual i, iN is the total number of aggressive interactions involving i, iL is the total number of aggressive interactions lost by i, and iQ is the average s(i) for all individuals engaged in aggressive interactions with i.The relative social rank among the members of the “6m” group was scaled from a winner/loser matrix by the Batchelder–Bershad–Simpson (BBS) method . The s(iijPI) of a pair of individuals i and j was defined as a simple proximity index [PI of each pair has a value from 0–1 and indicated the relative height of the proximity frequency for the pair in the “6m” group [iC(j) is the total number of sample points where j is the nearest neighbor to i, and iT is the total number of sample points for i. A proximity matrix was constructed using the PI among all pairs as elements.The nearest neighbor of each individual was recorded at 5 min intervals by the instantaneous sampling method . The proty index  and calcm” group . It reprm” group ,33,35. pairs or combinations of two members. The m” group . A sociaKr test). The kinship matrix served as the control and the correlation between the aforementioned matrices was then calculated with a matrix rank partial correlation test  [The relationship between mutual grooming and proximity for each pair was evaluated. The correlation between the grooming and proximity matrices was determined using Kendall’s tau correlation test (Tau Kr test) ,51. The F-test). In the former analysis, the objective variable was the total time of self-grooming observed for each individual and the explanatory variable was the total time of grooming received from other individuals during mutual grooming. In the latter analysis, the objective variable was the eigenvector centrality of each individual and the explanatory variable was s’.The relationship between the amount of self-grooming and mutual grooming of each individual, as well as the relationship between centrality in the social network and social rank of each individual, was examined by regression analysis  for the ethical use of animals.Our research was approved by the Teikyo University of Science Animal Committee (No. 18C015) and permitted by Kushima City, Miyazaki Prefecture. Our behavioral research adhered to the guidelines of the International Society for Applied Ethology  spent by each individual in self-grooming during the study period was 2174.8 ± 1346.6 s (N = 9). . .SD) spent by each individual in self-grooming during the study period was 477.0 ± 351.5 s (N = 9) . In one bout, the symmetrical state (62.4 ± 54.7 s) was linked to a pausing state (21.0 ± 33.7 s) or short asymmetrical state (1.4 ± 4.0 s). The total duration of symmetrical and asymmetrical grooming was 2123 s (97.8%) and 47 s (2.2%), respectively.Mutual grooming was confirmed for 6/9 horses: two stallions (“6m” and “16m”), three adult mares , and one colt (“76m”). There were 84 bouts . All obs (N = 9) . The meaβ = −0.195; R2 = 0.559; F1,7 = 8.888; p = 0.020).There was a significant negative correlation between the total time each individual spent in self-grooming and the total time each individual was groomed by another in mutual grooming . The fifth- and sixth-ranked individuals were categorized into the middle-ranked group (“20f” and “94f”). The seventh- to ninth-ranked individuals were placed in the lower-ranked group  (A winner/loser matrix is shown in d “75f”) .PIs among all “6m” members were >0 (PI > mean + SD (= 0.1387). According to the PI between pairs, the social network of the “6m” group was structured such that the first-ranked male (“6m”) occupied the central position and connected to three different subgroups (PI between “20f” and “90f” was the highest for the entire “6m” group (s’) of each individual .The  were >0 . For tenubgroups . The firm” group . No signKr = −0.218; p = 0.3040). A significant negative correlation was found between the kinship and aggression matrices . A significant positive correlation was found between the kinship and proximity matrices .No significant correlation was found between the kinship and grooming matrices ; however, a positive partial correlation was found between them when correcting for kinship . The correlation between the aggression and grooming matrices was not significant . No partial correlation was found between them even after kinship correction . No significant positive correlation was found between the aggression and proximity matrices ; however, a significant partial correlation was found between them after correcting for kinship .No significant correlation was found between the grooming and proximity matrices (The social network of the “6m” group based on its proximity relationships had a structure centered on “6m,” who was connected to three different subgroups. Individuals with higher ranks did not necessarily have higher group eigenvector centrality. Only those in the upper ranks were in proximity to “6m/” The middle-ranked individuals, “90f” and “94f,” maintained proximity to “6m”, mediated by the upper-ranked individual “20f.” All three lower-ranked individuals were siblings of ‘73f’ and had proximity to each other. The proximity between “73f” and “6m” indirectly maintained those between the lower-ranked individuals and “6m” . The cloThese results corroborate those of previous reports. Individual feral horses of similar rank on Yururi Island in Hokkaido maintain proximity to each other ,24,33, aA significant positive partial correlation was found between the grooming and proximity matrices when kinship was controlled. This finding upholds the affiliative relationship strengthening hypothesis. A significant positive correlation was also found between the aggression and proximity matrices when kinship was controlled. This result supports the hypothesis that proximity facilitates aggressive interactions between pairs. In contrast, no significant correlation was found between the aggression and grooming matrices here and the worsened relationship restoring hypothesis was not corroborated.On Yururi Island in Japan, the individual free-ranging horses most often in proximity differ from those frequently engaging in mutual grooming . The curIf mutual grooming frequency increases with pair proximity, then mutual grooming frequency and aggressive interactions should be positively correlated. However, no significant correlation was found between aggression and mutual grooming between members of the “6m” group in the present study. The results of this study did not enable the estimation of the causal relationships of the effects of interactions between pairs on affiliative relationships. Pairs of related or unrelated individuals that frequently participate in mutual grooming have closer proximity . ConsequThe present study also upheld the parasite removal hypothesis. Individuals that spent less time on self-grooming invested longer times receiving grooming from other individuals. This discovery may suggest that mutual grooming has not only an aforementioned social function, such as strengthening affiliative relationships, but also a maintenance function, such as parasite removal ,32.In mutual grooming, both horses benefit from hygienic maintenance as they both groom and are groomed ,56. HereMutual grooming between two primates strengthens affiliative relationships as they must both actively maintain interaction symmetry ,4,5,56. The present study supported the strengthening affiliative relationship and parasite removal hypotheses but did not corroborate the relationship restoring hypothesis. However, this study is merely a single case report based on relatively short observations made for one Misaki feral horse herd group when they were highly aggregated during a particular season. The aforementioned hypotheses must be tested on multiple herds and in longer-term observations of Misaki and other feral horses worldwide and can be extrapolated to understand behavioral stereotypies in horses in intensive production systems. The findings of this study suggest that comparisons between horses and other taxa, such as primates, may effectively elucidate the mechanisms by which interactions between group members maintain and strengthen their social relationships ,54,57.


Hearing loss is highly prevalent and associated with reduced well-being in older adults. But little is known about the role of social factors in the association of hearing difficulty and its health consequences. This study aims to examine the association between self-reported hearing loss and health-related quality of life , and to investigate whether social engagement mediates this association.Data on 4035 older adults aged 60 years or above from a cross-sectional nationally representative database in China were obtained to address this study. HRQoL was measured by the Short Form 12 Health Survey (SF-12). Hearing loss was defined by a dichotomized measure of self-reported hearing difficulty, which has been proved to be sensitive and displayed moderate associations with audiometric assessment in elderly population. Social engagement was measured by the Index of Social Engagement Scale. Bootstrap test was applied to test for the significance of the mediating role of social engagement.Self-reported hearing loss was found negatively associated with HRQoL in older adults, and hearing loss was much more related to reduced mental well-being. Social engagement played a partial mediating role in the association of hearing loss and HRQoL. Social engagement account for 4.14% of the variance in the change of PCS scores and 13.72% for MCS, respectively.The study lends support to the hypothesis that hearing loss is associated with aging well beings, and the use of hearing aid or proper social engagement intervention may improve the quality of life among the elderly. Health-related quality of life (HRQoL), an important concept to describe subjective well-being, is defined as the quality of life that directly or indirectly related to health . It is aHearing loss, ranked as the third most prevalent chronic medical condition in older adults, only exceeded by arthritis and hypertension . ApproxiAccording to Social network theory, social network may influence health by promoting social participation and social engagement . Social In a society with a large number of poor aging population, it is of great significance to identify the impacts of age-related hearing deficits on health and to find out the potential social intervention approaches. Although there are growing evidences on the association between hearing loss and quality of life in western countries, few studies have been done on this issue in China , particuWe obtained data from Survey on the Aged Population of Low-income Families in Urban/Rural China (2018), which was conducted from July 1 to September 31, 2018. The survey was approved and sponsored by the Ministry of Civil Affairs of the People’s Republic of China and carried out by the Institute of Social Science Survey, Peking University. The purpose of this survey was to investigate the well beings, family conditions, physical and psychological health status, social support, social networks, and health service utilizations of older adults aged 60 years or above who live in low-income households. The results of this survey were considered as the scientific basis for the formulation and implementation of low-income household policies for national and local governments in China .Multistage, stratified and random-cluster sampling was used in this survey, which covered 155 counties (districts) and 1800 communities (villages) in 28 provinces, autonomous regions, and municipalities in China. Low-income family in this survey was defined as family whose annual household income per capita is below 1.5 times the local minimum living standard. Every three or four targeted households were matched with one geographically nearby general household as the control group. Home visits were conducted by trained investigators. All participants consented to participate in the survey, and the initial sample consisted of 6042 participants. In this study, we restricted our analysis to 4035 older adults living in low-income households with completed information on the questions we are concerned.The outcome variable of this study was the summary score of individual’s health-related quality of life. HRQoL was measured by the Chinese version 12-item Short Form Health Survey (SF-12), which has been tested with satisfactory reliability and validity in measuring health status of Chinese elderly population . SF-12 wThe independent variable in this study was whether an individual had a self-reported hearing loss. Participants were asked the following question to check their hearing status (with hearing aid): “Do you have any difficulty with your hearing? The answers were coded as: 1. very difficult; 2. have some difficulties in hearing; 3. can hear clearly.” In this study, hearing loss was defined by a response of self-perceived hearing difficulties. Self-reported hearing loss, being regarded as a subjective assessment of hearing functions limitation, was treated as a binary variable (yes vs. no) in this study. Self-assessed hearing loss among elderly population reflects hearing disability. The validation of self-reported hearing loss in health research have been examined in prior study, and the results demonstrated that the single question for hearing loss yielded reasonable sensitivity and was minimally affected by age and gender, which could be recommended for use in assessing the magnitude of health burden caused by age-related sensory impairment , 45.Social engagement was selected as a putative mediator variable based on theoretical assumptions from the literature. In this study, social engagement is assessed by the Index of Social Engagement (ISE), which was composed of six dichotomous items: (a) at ease interacting with others, (b) at ease doing planned or structured activities, (c) at ease doing self-initiated activities, (d) establish own goals, (e) pursues involvement in life of facility, and (f) accepts invitations into most group activities. The ISE scores ranged from 0 (lowest) to 6 (highest), and the scale demonstrated internal consistency and good reliability . A cutofCovariates in this study included sociodemographic, socio-economic, health behavior and health conditions characteristics, which were potentially associated with HRQoL according to previous studies , 12. TheP-value less than 0.05 was considered statistically significant. The software STATA 13.0 for Windows was utilized for statistical analysis.Descriptive analysis of the mean and distribution of the study variables were reported for the study population. Difference between the study variables and hearing status were assessed using Chi-square test for categorical variables  and a t test for continuous variables . A Linear regression was applied to identify the association of the presence of hearing loss with PCS and MCS HRQoL. Nonparametric bias-corrected case resampling bootstrap method, which was valid in testing a single-mediator model , was empTable The PCS scores of the sample was 42.10(SD = 7.37) and 41.11(SD = 11.47) for MCS scores, respectively. One thousand five hundred twenty-four participants (38.07%) were self-reported with hearing loss and the mean scores of ISE was 3.94(SD = 1.95).Table p < 0.001). Compared with those without hearing loss, older adults with hearing loss had 1.92-point lower PCS scores and 2.76-point lower MCS scores, respectively. After adjusting for socio-demographic, SES and health conditions in Model 2, the association between hearing loss and health-related quality of life (both PCS and MCS) remained significant (p < 0.001). Age, sex, education, household income per capita and the number of chronic diseases were associated with HRQoL. Female and illiteracy had higher risk in lower PCS and MCS. As household income per capita increased, older adults were more likely to report better HRQoL. Moreover, with the number of chronic diseases increasing, the HRQoL of individuas tend to be lower.The multivariate association between HL and HRQoL (PCS and MCS), as well as the mediating role of social engagement in this relationship are shown in Table Two OLS regressions were used to identify the mediating role of social engagement in the association between hearing loss and HRQoL. In Model 3, we used social engagement as a dependent variable and found that hearing loss was negatively associated with social engagement. In Model 4, after adjusting for social engagement and other covariates, hearing loss remained significantly associated with lower levels of PCS and MCS. Social engagement was related to HRQoL positively that social engagement raised in 1 score would be associated with 0.20-point increase in PCS and 1.14-points increase in MCS, indicating that social engagement played a meditating role in the linkage between HL and HRQoL.Figure In the context of aging society with increased risk of chronic illness and a national policy implementation of poverty elimination, physical stressor’s impacts on well beings of individuals facing dual burden of aging and poverty have become growingly important social and health concerns. In this study, we conceptualized hearing loss as a chronic physical stressor, and estimated whether it was associated with health-related quality of life in a sample of older adults with poverty, utilizing a nationally representative survey data from China. Based on social network theoretical framework, we further tested whether social engagement played a mediating role in the relationship between HL and HRQoL.First, our findings indicate that hearing loss was negatively associated with health-related quality of life among older adults with poverty in China. The impact of hearing loss on PCS and MCS remained statistically significant after controlling socio-demographic, SES and health related conditions. Our results comported well with previous studies which were relied on both standardized audiometric measurement techniques and self-perceived hearing loss, that impairment of hearing acuities was correlated to decreased scores on quality of life , 49. AcqSecond, our results suggest that social engagement played a mediating role in the association of hearing loss and PCS and MCS. This result indicated that older adult’s social interactions with friends and family mediated the linkage between hearing loss, a common sensory impairment in older adults, and their physiological or psychological health , 54. SocOlder adults with hearing loss may have difficulties in communication due to decline in hearing sensitivity . HearingMeanwhile, there are also some limitations in this study. Firstly, our survey relied on self-reported hearing impairment with hearing aids, and the validity of these complaints could not be confirmed. Estimates based on self-reported sensory deprivation may be inaccurate given the tendency of older individuals to deny or underestimate their hearing difficulty. Secondly, since the medical history for auditory function as well as the severity of hearing loss were not known, we are not able to measure the impact’s duration of hearing loss exerting on HRQoL. Additionally, the causal relationship between hearing loss and HRQoL could not be verified, in that the descriptive, correlational, cross-sectional design was employed in this study.Despite these limitations, the strengths of this study are also evident, including not only using a nationally representative population-based data in China to evaluate the association between self-reported hearing loss and HRQoL in older adults with poverty, but also identifying the role of social engagement in mediating the relationship. To our best knowledge, this is the first study to analyze the association between hearing loss and quality of life, along with the role of social engagement as a mediator among the older adults with poverty in China. Findings of this study have public health implications for Chinese policy makers to consider the importance of audiologic rehabilitation programs and the role of social support or social engagement in promoting quality of life among the elderly.Hearing loss is negatively associated with physical and mental health related quality of life among older adults with poverty in China. Social engagement mediates the linkage between hearing loss and HRQoL. In accordance with the stress-buffering and social network theory, hearing deficit, as a chronic physical stressor, can lead to poorer well-being, while social interactions could buffer (mediate) this relationship. Improvement in auditory function and social participation may contribute to promoting quality of life. Further studies are warranted to confirm our findings and to reveal the mechanism of hearing loss affecting quality of life, which will help identify the priority of hearing and health interventions for older adults.


Hearing impairment is the most frequent sensory deficit in humans, affecting more than 360 million people worldwide. In fact, hearing impairment is not merely a health problem, but it also has a great impact on the educational performance, economic income, and quality of life. Hearing impairment is therefore an important social concern.We aimed to evaluate and compare the accuracy of self-perception, Hearing Handicap Inventory for the Elderly-Screening (HHIE-S) questionnaire, free-field voice test, and smartphone-based audiometry as tests for screening moderate hearing impairment in older adults in China.In this study, 41 patients were recruited through a single otology practice. All patients were older than 65 years. Patients with otorrhea and cognitive impairment were excluded. Moderate hearing impairment was defined as mean hearing thresholds at 500, 1000, 2000, and 4000 Hz >40 dB hearing loss (pure-tone average > 40 dB hearing loss). All patients completed 5 hearing tests, namely, the self-perception test, HHIE-S questionnaire test, free-field voice test, smartphone-based audiometry test, and standard pure-tone audiometry by the same audiologist. We compared the results of these tests to the standard audiogram in the better-hearing ear.The sensitivity and the specificity of the self-perception test were 0.58 (95% CI 0.29-0.84) and 0.34 (95% CI 0.19-0.54), respectively. The sensitivity and the specificity of the HHIE-S questionnaire test were 0.67 (95% CI 0.35-0.89) and 0.31 (95% CI 0.316-0.51), respectively. The sensitivity and the specificity of the free-field voice test were 0.83 (95% CI 0.51-0.97) and 0.41 (95% CI 0.24-0.61), respectively. The sensitivity and the specificity of the smartphone-based audiometry test were 0.92 (95% CI 0.60-0.99) and 0.76 (95% CI 0.56-0.89), respectively. Smartphone-based audiometry correctly diagnosed the presence of hearing loss with high sensitivity and high specificity.Smartphone-based audiometry may be a dependable screening test to rule out moderate hearing impairment in the older population. Hearing impairment affects more than 5% of the world’s population. In 2012, the World Health Organization released new estimates on the magnitude of disabling hearing loss >40 dB hearing loss). The results of the hearing tests were entered into 2 × 2 tables. Sensitivity, specificity, negative likelihood ratio, and the positive likelihood ratio were calculated.In our study, 41 patients were recruited, of which 27 were men and 14 were women. The mean (SD) age of the patients was 72.32 (6.81) years. The mean (SD) hearing thresholds at 500, 1000, 2000, and 4000 Hz of standard pure-tone audiometry was 36.29 (15.57) dB. More than 50% of the world’s population live in low-income countries. People with hearing impairments in low-income countries account for 80% of the world’s associated population . Thus, mIn industrialized countries, well-established audiology equipment is available for audiology practice. The huge gap in the provision of audiology services between industrialized and low-income countries can barely be filled by volunteer audiologists or by developing new hearing screening methods. Therefore, we aimed to develop some fast, easy-to-use, and reliable methods for low-cost hearing screening tests. All the different methods shown in our study for screening hearing impairments have advantages and disadvantages. Smartphone-based audiometry has higher sensitivity and higher specificity than the other screening methods for detecting moderate hearing impairment in the older adults.The first screening method for hearing impairment in this study was the self-perception hearing screening test. Self-reported data to assess the presence of diseases or disorders have been used frequently in large-scale epidemiologic survey studies in the past . StudiesThe second screening method for hearing impairment in this study was the HHIE-S questionnaire hearing screening test. The screening version of the HHIE-S questionnaire is the most widely applied test that is validated. The HHIE-S questionnaire is a 10-item, self-administered questionnaire that was developed to measure the emotional and social handicap . The ASHThe use of speech to determine hearing impairment level has been used for a long time. The hearing impairment level can be assessed by a primary health care doctor by using the free-field voice hearing screening test. It is surprising that the free-field voice hearing screening test is still performed nowadays. In an industrialized country like United Kingdom, primary health care doctors are obliged to screen the older adult population for hearing impairment, as listed in the 1990 National Health Service contract  showed tIn recent years, there has been a rapid evolution in the development of mobile health services. Smartphone-based audiometry is considered as a fast, easy, and reliable technique for cost-effective screening of hearing impairments. Free apps can be downloaded from the Android market and installed in any smartphone. Smartphones have the ability to control the audio output and frequency. However, given that there are difficulties with calibration, in terms of sound output levels and timing uncertainty, the applicability of smartphones and standard pure-tone audiometry is limited. A total of 18 patients were considered to have moderate hearing impairment in the smartphone-based audiometry hearing screening test, of which 11 tested positive for moderate hearing impairment. The smartphone-based audiometry hearing screening test had a sensitivity of 0.92 (95% CI 0.60-0.99) and specificity of 0.76 (95% CI 0.56-0.89), with a positive likelihood ratio of 3.80 (95% CI 1.95-7.4) and negative likelihood ratio of 0.11 (95% CI 0.02-0.73). Szudek et al -27, probIn conclusion, all the different methods mentioned in this study are available for hearing screening but they all have advantages and disadvantages. Smartphone-based audiometry has higher sensitivity and higher specificity for detecting moderate hearing impairment in older populations. Prospective randomized clinical studies are still needed to test the application of smartphone-based audiometry in the field of screening for hearing impairment in older populations. Nevertheless, we recommend that in low-income countries where specialized audiological services and proven audiometric equipment are not available, primary health care givers should be trained to administer simple smartphone-based audiometry as an acceptable alternative hearing assessment for older adults who have complaints with regard to hearing impairment.


We found that 11 TCs were significantly altered in 5 min of flight-induced and vector-averaged gravity. Among the annotated clusters were G3BP1, KPNB1, NUDT3, SFT2D2, and POMK. Our results revealed that less than 1% of all examined TCs show the same response in vag and flight-induced microgravity, while 38% of differentially regulated TCs identified during the hypergravity phase of the suborbital ballistic rocket flight could be verified with a 9× g ground centrifuge. In the 2D clinostat system, doing one full rotation per second, vector effects of the gravitational force are only nullified if the sensing mechanism requires 1 s or longer. Due to the fact that vag with an integration period of 1 s was not able to reproduce the results obtained in flight-induced microgravity, we conclude that the initial trigger of gene expression response to microgravity requires less than 1 s reaction time. Additionally, we discovered extensive gene expression differences caused by simple handling of the cell suspension in control experiments, which underlines the need for rigorous standardization regarding mechanical forces during cell culture experiments in general.Cellular processes are influenced in many ways by changes in gravitational force. In previous studies, we were able to demonstrate, in various cellular systems and research platforms that reactions and adaptation processes occur very rapidly after the onset of altered gravity. In this study we systematically compared differentially expressed gene transcript clusters (TCs) in human Jurkat T cells in microgravity provided by a suborbital ballistic rocket with vector-averaged gravity (vag) provided by a 2D clinostat. Additionally, we included 9×  Earth’s gravitational force has been a constant condition during Earth’s history and the evolution of cells and organisms . The humGF) is one of the four fundamental physical forces in nature, has an attracting character, and correlates linearly with an object’s mass. Newton’s law of gravity describes GF as the product of two objects’ masses  attracting each other, divided by the square of the distance (r), and scaled by the gravitational constant (G): GF = G(m1m2/r2). To calculate the gravitational force exerted on an object on Earth, this formula can be simplified by setting the distance between the center of the Earth and the object equal to the Earth’s radius (R⊕) and by combining G, Earth’s mass (M⊕), and R⊕ into the gravitational acceleration constant g = 9.81 m/s2, yielding GF = mg. As described by Einstein in his work on general relativity, there is no difference between the observation of a mass falling down in a steady reference system  and a resting mass in a reference system that is linearly accelerated towards the mass (related to as inertia mass). As consequence, the gravitational force exerted on an object is only measurable if the reference system is not accelerated in the same way, as for instance the International Space Station (ISS) in low Earth orbit. The ISS’s actual gravitational acceleration, g, that would be measurable if it was not accelerated, is only reduced by 8% due to the slightly greater distance to the Earth’s center [−3 and 10−6g [Gravitational force  and sedimentation of particles in a solution  are absent. Entropy-driven diffusion of particles resulting from temperature dependent Brownian motion is present, whereas concentration dependent  convection as a cause of buoyancy is absent. Therefore, mixing of liquids is affected by altered gravity .All these changes occur in altered gravity environment and have the potential to affect biological processes. Due to the restriction of microgravity flight platforms, ground based facilities (GBFs) have been developed to simulate microgravity conditions in biological experiments .Since all GBFs are ground based, none of them is able to provide true force-free conditions. By averaging forces, those devices attempt to simulate microgravity. Due to the logistical and cost advantages, the popularity of GBFs is high, although the validity of GBFs in terms of producing results comparable to flight-induced microgravity platforms remains uncertain. Clinostats rely on the principle of constantly turning a sample, thereby averaging out the gravitational force vector around one (1D/2D clinostat) or two (3D clinostat) axes. Technically speaking, the gravitational force still acts on the sample, but the direction of the gravitational vector on the sample is changing constantly. This is why the terminology "vector-averaged gravity" (vag) is usually preferred over "simulated microgravity” . Whetherg control conditions in microgravity experiments [FZ f) is dependent on the rotation angular frequency (ω = 2π f), the radius (r) from the center, and the object’s mass (m): FZ f = mω2r = m 2π f r. With known dimensions of the centrifuge the (simulated) gravitational force can be tuned by varying the rotation frequency. Centrifuge setups with adherent cells are prone to shear forces, if the geometry of the vessel where cells are rotated in does not match the rotation circle (for example for flat bottom vessels) [m being the object’s mass, ω = 2π f being the centrifuge’s rotation angular frequency and v being the object’s speed. In a liquid, molecules and particles move around freely which is described by Brownian motion and therefore being influenced by the Coriolis force. As a consequence, particles diffuse much slower during ultracentrifugation and show an elliptic and no more ball-shaped diffusion pattern [Several mechanisms induced in microgravity are also sensitive to hypergravity ,4. Fixederiments . The undvessels) ,37. Addi pattern . This efg centrifuge experiments. Thus, we performed ground based studies in a 2D clinostat and a hypergravity centrifuge using comparable experimental conditions to the parabolic flight and suborbital ballistic rocket experiments. Our aim was also to investigate if the underlying mechanisms for the perception and transduction of the gravitational force into chromatin is faster or slower than the time needed in a 2D clinostat to average gravitational force in all directions once, meaning one revolution per second. If the transcriptome effect of flight-induced microgravity can be reproduced in a 2D clinostat, the process of primary gravity perception must take longer than 1 s.Although several types of cultured cells are sensitive to gravity ,40, the g average and 8.1× g peak, and the second one (stage 2 motor) had a duration of 28.2 s and a thrust acceleration of 6.7× g average and 12.6× g peak, with an additional spin of 2.8 Hz. The pull-up-phase of the parabolic trajectory of the Airbus A310 ZERO consisted of 22s hypergravity up to 1.8× g. For this reason, we included different types of control experiments  and hypergravity (hyp-g) experiments. Due to the ballistic flight trajectory, it is an inherent limitation of the parabolic flight and suborbital ballistic rocket microgravity platforms that the launch and hypergravity phase is preceding the microgravity phase. The launch phase of TEXUS-51 consisted of two phases: the first one (stage 1 motor) had a duration of 12.2 s with a thrust acceleration of 5.1× eriments .g GC: 1× g on ground in the experiment hardware under identical conditions as in the rocket except the gravitational force, (4) 1× g IF: 1× g in-flight during the 5 min microgravity phase using an on-board centrifuge, and (5) CC: under regular cell culture conditions at 1× g to control the hardware effect (g control samples (1× g control) were prepared similarly and placed on the base plate of the clinostat to monitor instrument effects such as vibrations. A further 1× g control  was prepared, in which cells were aspirated into the pipette and immediately drained again to monitor potential effects based on the pipetting procedure. GBF hypergravity experiments were performed by installing pipettes filled with human Jurkat T cells in a centrifuge and rotated at 9× g for 5 min at 37 °C . For both experiment platforms, total RNA from at least five samples was processed for each group and hybridized on microarray chips.During the suborbital rocket experiment TEXUS-51, the following cell samples were obtained: (1) TX hyp-g: 75 s after launch, i.e. after the hypergravity phase and before the microgravity phase, (2) TX µg: after 5 min of microgravity, (3) H/W 1× e effect . In the at 37 °C . The chog for the same time period 5778 TCs, i.e., more than five-fold, were identified to be differentially regulated. In the direct comparison of the two ground based facilities (2D clinostat vs. 9× g centrifuge), 962 TCs were differentially expressed (g control vs. BL), in order to exclude hardware and vibration induced gene expression differences, 871 TCs and 4596 TCs were identified to be differentially expressed during clinorotation (2D clinostat vs. 1× g control) and 9× g centrifugation (9× g centrifuge vs. 1× g control), respectively (g control) were −1.38 and +1.39 with minimum and maximum values of −2.22 and + 2.38, respectively. Hypergravity sensitive TCs (9× g centrifuge vs. 1× g control) showed average fold change numbers of −1.44 and +1.52 with minimum and maximum values of −4.00 and +4.28, respectively. The direct comparison of 2D clinostat with 9× g centrifuge revealed 752 differentially expressed TCs (after subtraction of control) with average fold change values of −1.40 and +1.41 with minimum and maximum of −2.12 and +2.43, respectively  and hypergravity-sensitive  transcripts identified in the TEXUS-51 experiment were directly compared to the results from the GBF study.The results of the GBFs experiments were compared to the results of the TEXUS-51 suborbital rocket experiment in order to evaluate the validity of the GBFs in preliminary studies to test experiment designs and pre-select experiment parameters for later suborbital rocket missions. For this purpose, the flight-induced microgravity-sensitive , we were able to identify 396 microgravity-sensitive (TX µg vs. 1× g IF), 346 hypergravity-sensitive (TX hyp-g vs. 1× g IF) and 19 TCs expressed differentially in the comparison TX µg versus TX hyp-g (g IF) were −1.36 and +1.40 with minimum and maximum values of −1.83 and +1.85, respectively. Hypergravity-sensitive TCs (TX hyp-g vs. 1× g IF) showed average fold change numbers of -1.36 and +1.45 with minimum and maximum values of −1.92 and +1.94, respectively. The direct comparison TX µg versus TX hyp-g revealed average fold change values of −1.39 and +1.37 with minimum and maximum of −1.68 and +1.43, respectively (g IF and TX hyp-g vs. 1× g IF) revealed 134 TC hits  could be identified which were differentially regulated in hypergravity and vag . This cod change .A cross platform comparison should benchmark how comparable the results of the GBFs experiments are with those of the TEXUS-51 suborbital flight. In case of the hypergravity-sensitive transcripts, 42 TCs (28 annotated TCs belonging to 25 genes) were identified in both platforms , Table 6g centrifuge. Conversely, from the 5778 differentially expressed TCs identified in hypergravity of the 9× g centrifuge, only 26%, roughly one quarter, were also found to be differentially regulated during the hypergravity phase of a suborbital ballistic rocket flight.To assess the effects of strict filtering (strictly controlled) that have been used to avoid false positive hits of differentially expressed TCs a, differg centrifuge and suborbital rocket. During the hypergravity phase of the TEXUS-51 suborbital rocket flight, 104 TCs were identified to be upregulated and 242 TCs were downregulated, while 43049 TCs showed no response. From the 104 upregulated TCs, we identified 29 TCs (28%) as also upregulated in the 9× g centrifuge experiment. One TC was downregulated, 60 TCs showed no response and 14 were excluded (“eliminated”) by control comparisons. In case of the 242 downregulated TCs of TEXUS-51, four TCs (2%) were also downregulated in the 9× g centrifuge experiment, eight TCs were upregulated, 198 TCs displayed no response, and 32 were eliminated in control comparisons. From the 43049 non-responsive TCs of the hypergravity phase of the TEXUS-51 mission, 40909 (95%) were also non-responsive in the 9× g centrifuge experiment. However, a large number of the non-responsive TCs identified in the TEXUS-51 platform were found to be differentially expressed in the 9× g centrifuge experiment (1011 upregulated and 448 downregulated).Relative to the total number of TCs examined (43395), 33 TCs (< 0.1%) showed a continuous response to hypergravity, 267 TCs (0.6%) an adaptation, 1459 TCs (3.4%) a late response and 40909 TCs (94.3%) no response at all. Meanwhile, 727 TCs (1.7%) were eliminated in control comparisons .Relative to the total number of TCs examined (43395), nine TCs (< 0.1%) showed the same response in flight-induced and vag, 358 TCs (0.8%) showed no or reverse response, 215 TCs (0.5%) were sensitive only to vag, and 42086 TCs (97.0%) displayed no response at all. Further, 727 TCs (1.7%) were eliminated in control comparisons .g control, most of the differentially regulated TCs  can also be found in the comparison 9× g centrifuge versus 1× g control. For the primary comparison TX µg versus 1× g IF representing differential gene expression in flight-induced microgravity, only 11.6% of the upregulated and 1% of the downregulated TCs can be confirmed in vag (2D clinostat vs. 1× g control). Interestingly, the major part of the TCs can also be found in the hypergravity comparison 9× g centrifuge vs. 1× g control (34.8%) and TX hyp-g vs. 1× g IF (73.91% of the upregulated TCs and 21.81% of the downregulated TCs). Regarding the primary comparison 9× g centrifuge versus 1× g control, 16.3% of the upregulated and 6.8% of the downregulated TCs could be confirmed in the comparison 2D clinostat versus 1× g control. In case of the primary comparison TX hyp-g vs. 1× g IF, about one third (32.2%) of the upregulated TCs could be confirmed to be upregulated in the comparison 9× g centrifuge versus 1× g control. Additionally, 56.7% of the upregulated and 31.0% of the downregulated hypergravity-sensitive TCs could be verified in flight-induced microgravity, indicating that many of the identified TCs are hypergravity and microgravity “double sensitive”.g centrifuge. Both platforms hold the same type of pipettes containing cell samples. During 5 min of vag in the clinostat, we found 768 significantly upregulated and 373 significantly downregulated TCs compared to 1× g controls, while 5 min of 9× g hypergravity induced 3046 significantly upregulated and 2732 significantly downregulated TCs. The baseline control (1× g control vs. BL) revealed 2125 significantly upregulated and 496 significantly downregulated TCs, reflecting the influence of filling of the cell suspension into the pipettes and releasing the cell suspension from the pipettes  were significantly altered using both research platforms . Among tG3BP1, (2) KPNB1, (3) NUDT3, (4) SFT2D2, all of which have already been identified as vag/flight-induced microgravity-sensitive  ensitive .g centrifuge experiments showed more up than downregulated TCs. We could not observe this effect in the data of the TEXUS-51 mission. Here, no major differences between the number of hypergravity and flight-induced microgravity-sensitive TCs were observed, and the differentially expressed TCs were rather downregulated instead of upregulated  and were cultured in RPMI1640 medium , supplemented with 10% fetal bovine serum , 2 mM glutamine , and 100 U/mL penicillin, as well as 100 µg/mL streptomycin . The Jurkat cells were subcultured every other day and reseeded at a density of 0.2 × 106 cells/mL. A trypan blue assay was used for the quantification and assessment of cell viability (between 97% and 100%). The measured population doubling time ranged between 24 and 28 h.The standard cell culture conditions for the human cell line Jurkat T cells  were described previously ,4. Brief−5× g), (iii) 8.1× g first stage peak thrust acceleration, (iv) 5.1× g mean thrust acceleration, (v) first stage burnout at 12.1 s, (vi) engine separation at 13.4 s, (vii) 12.6× g second stage peak thrust acceleration, (viii) 6.7× g mean thrust acceleration, (ix) burnout at 43.2 s, (x) yo-yo despin at 56.0 s, and (xi) motor separation at 59.0 s.TEXUS-51 was a German Center for Aerospace (DLR) funded suborbital ballistic rocket mission. The vehicle assembly comprised the experiment payload on top of a two-stage VSB-30 rocket motor. The rocket launch was performed on 23 April 2015 at 09:35 from the ESRANGE Space Center in Sweden. Excerpt of the flight profile: (i) altitude: 258 km, (ii) total microgravity time: 369 s , 7 × H/W 1× g GC, 9 × 1× g IF, 7 × BL-TX hyp-g and 9 × µg.Human Jurkat T cell culture was performed as previously described ,14,55,56g at 37 °C for 300 s  and 12.6× g (second stage peak thrust acceleration). For control experiments, pipettes filled with Jurkat cells were placed on the base plate of the clinostat. These 1× g hardware controls were exposed to all non-clinorotation hardware effects including instrument vibration for 300 s. A fourth sample group representing a pre-experiment baseline including potential shear forces acting on the cells by aspiration and draining out of the pipette was performed to monitor the effects of the filling procedure. After the respective incubation times, cell samples were mixed with 1 mL TRIzol LS  and homogenized with a needle  and a syringe. Total RNA was purified as described in the following Ground based simulation of microgravity is a common technique to pre-test and prepare spaceflight experiments. In our experiments, 2D clinorotation  and centrifugation  were used for vag and hypergravity experiments, respectively. For vag and centrifugation experiments, human Jurkat T cells from the same cell pool were used for both experiment conditions. Then, 0.8 mL of cell suspension (25 million cells) was filled in a 1 mL pipette  corresponding to the total amount of cells per sample in the TEXUS-51 experiment. One end or both ends of the pipettes were sealed by rubber plugs depending on whether they were used for clinorotation or centrifugation. Pipettes containing Jurkat cells were then either placed in the 2D clinostat rotating with a speed of 60 rpm or in the centrifuge set to 9× or 300 s . The cenA detailed protocol has been published previously ,14,55,56p-value (one-way ANOVA) of <0.05 were considered to represent a significantly differential gene expression. The large number and homogeneity of the applied samples resulted in a low variance within the sample groups and a high sensitivity of the applied method.A detailed description of RNA sample processing and microarray data analysis can be found in previous publications ,14,55,56To exclude that fold changes measured in the primary microgravity and hypergravity comparisons were due to gravitational or other conditions preceding the respective phase, controls were applied: Intersections were built between the primary comparison and the comparison that represents the previous phase. Transcripts that were shown to be differentially expressed already in the preceding phase were excluded from the pool of microgravity and hypergravity-sensitive Transcripts see a.To elucidate if transcripts were either only vag respectively flight-induced microgravity-sensitive, hypergravity-sensitive, or sensitive to both conditions within one experimental platform (intra-platform), intersections between the pools of vag respectively flight-induced microgravity and hypergravity-sensitive transcripts were made. Furthermore, we analyzed if transcripts responded to vag respectively flight-induced microgravity or hypergravity in both experimental platforms by inter-platform intersections.https://david.ncifcrf.gov/summary.jsp). As background lists “Homo sapiens” was used, and for compiling the functional annotation chart the GENE-Ontology terms “GOTERM_BP_DIRECT”, “GOTERM_CC_DIRECT”, and “GOTERM_MF_DIRECT" were applied. Compilation of a functional annotation chart was performed with the Functional Annotation Tool DAVID , accession no. GSE101102.The data sets analyzed for this study are available in the GEO (Gene Expression Omnibus) repository (


Some studies have shown sensory impairment is associated with impaired cognitive test performance, however tests rely to varying degrees on hearing and vision. We hypothesized scores for cognitive tests whose administration depends on vision or hearing are biased among those with vision or hearing impairment, respectively, after controlling for underlying cognitive performance. We used item response theory methods to test for differential item functioning (DIF) by hearing and vision impairment in the Baltimore Longitudinal Study of Aging (BLSA) and the Atherosclerosis Risk in Communities study (ARIC). We identified DIF by hearing impairment for tests that do not rely on hearing and DIF by vision impairment for tests that do not rely on vision. We found no clinically meaningful differences between unadjusted and DIF-adjusted measures of cognition. Our finding that DIF by sensory domain was independent of administration modality suggests cognitive load may play a larger role than previously acknowledged.


The aim of this study was to explore the association between employment status and World Health Organization Disability Assessment Schedule, Second Edition (WHODAS 2.0) scores of working-age subjects with hearing impairment. The data of 18,573 working-age subjects (age ≥ 18 and <65 years) with disabling hearing impairment were obtained from the Taiwan Data Bank of Persons with Disability (TDPD) for the period from 11 July 2012 to 31 October 2018. Demographic data and WHODAS 2.0 scores for each domain were analyzed to identify their relationship with employment status. Unemployed subjects with disabling hearing impairment had higher WHODAS 2.0 scores in all domains compared with the employed subjects. Binary logistic regression revealed that older age, female sex, lower educational level, institutional residence, rural residence, lower family income, and moderate to severe impairment were more strongly associated with unemployment status. The data in this large population-based study offer comprehensive information on important factors associated with the employment status of people with disabling hearing impairment. Early identification of risks of unemployment of patients with hearing impairment can raise awareness for aggressive community and government campaigns regarding public health to improve the self-confidence, social participation, and related psycho-social wellbeing of people. According to a World Health Organization (WHO) report updated in March 2018, more than 5% of the world population (estimated 466 million people) had disabling hearing loss compared with 360 million people in 2013. Moreover, it is estimated that more than 900 million people will have disabling hearing loss by 2050, which is approximately one in every 10 people [To prevent a disability becoming a handicap, a framework was developed by the WHO to evaluate the functions and disability conditions in a holistic and multidimensional manner as the International Classification of Functioning, Disability and Health (ICF) in 2001. The ICF links bodily function and structure with activities limitations and participation restrictions by considering environmental and personal factors and incorporating them into a bio-psycho-social model composed of “Health Condition,” “Contextual Factors,” “Body Functions and Structures,” and “Activity and Participation” for understanding the roles and significance of impairments in the view of individuals and society as a whole. It was designed as an international standard and a comparative benchmark for describing and measuring the effects of health conditions on the functionality and disability worldwide . ICF corTo comprehensively evaluate and quantify the disability level, an objective assessment tool that measures physical and psycho-social aspects is essential. On the basis of the ICF framework concepts, the WHO Disability Assessment Schedule, Second Edition (WHODAS 2.0) was proposed by the WHO as a feasible tool for assessing factors associated with functional disability and analyzing the risk factors responsible for these disabilities, while closely corresponding to the ICF component of activities and participation . WHODAS Cornelius et al. used WHODAS 2.0 to analyze the association between the six subdomains of disabled individuals and future work status, but only focused on the possibility of working retrieval in relation to unemployment benefit claim . Our prep < 0.001) among adults in the United States was proposed based on the 2006 and 2008 Medical Expenditure Panel Survey; however, other advanced psycho-social factors were not investigated [However, the data for the effect of hearing disability on working status are lacking. An association of hearing loss with decreased employment and less wage income , was developed on the basis of the ICF framework for individuals with functional impairment to apply for disability certification and receive social welfare subsidy from the government in Taiwan. Simultaneously, the Taiwan Data Bank of Persons with Disability (TDPD) was established . The DESA total of 18,573 patients with hearing disability aged between 18 and 64 years from 11 July 2012, to 31 October 2018, were enrolled from the TDPD database. The enrolled patients had ICD-10-CM codes H91.8X1, H91.8X2, H91.8X3, H91.8X9, H91.10, H91.11, H91.12, H91.13, H91.90, H91.91, H91.92, and H91.93 or ICD-9-CM codes 389.8, 389.9, 389, 388.01, and 388.11. Demographic data such as age, sex, residential status (community dwelling or institution), urbanization level , socioeconomic status of family , education level , employment status, and WHODAS 2.0 scores  were obtained from TDPD. ICF categories with severity of body function and body structure were recorded, and results revealed severe hearing impairment (ICF category b230). Mild, moderate, and severe disability in hearing function were defined as hearing handicap (HH) in both ears between 50% and 70%, between 71% and 90%, and >90%, respectively, with b230.3 implicating severe impairment. Patients younger than 18 years or older than 65 years were excluded from the study because they were not within the legal age of labor force of Taiwan .The employment status was defined as working either full time or part time with salary level meeting the regulation set by the Department of Labor in Taiwan. The definition of the severity of hearing impairment indicated as HH with percentage loss of hearing worksheet, suggested and modified by American Academy of Otolaryngology by using pure-tone average of thresholds at frequencies 0.5, 1, 2, and 4 KHz in calculating equations . This stThe 36-item traditional Chinese version of WHODAS 2.0 scores was designed by authorized specialists after they interviewed the patients (or their proxies if patients were not able to answer the questions). WHODAS 2.0 has six domains and 36 items in total, including six items on cognition (Domain 1); five items on mobility (Domain 2); four items on self-care (Domain 3); five items on getting along with people (Domain 4); eight items on life activities , and eight items on social participation (Domain 6). The patients indicated their level of difficulty in performing activities related to each item in the past 30 days on a 5-point Likert scale . Each domain score and summary scores were transformed to standardized scores ranging from 0 to 100, with higher scores indicating higher severity of disability . The foup value was < 0.05.The demographic data are presented as numbers and percentages. The chi-square test was used to compare categorical variables between male and female patients. Patients were classified into two groups, namely employed and unemployed, depending on their work status when undergoing the DES-2012 assessment process. The Wilcoxon rank sum test was used for comparing the continuous variables of the standardized WHODAS 2.0 summary and six domain scores between the employed and unemployed groups. We applied binary logistic regression to determine the unemployment risk by using baseline variables, such as age, sex, education, residence, urbanization level, family income, and severity of impairment. The data were analyzed using SAS 9.4 . The differences or correlations were considered significant if the n = 10,155 and women, n = 8418).Data of 53,627 subjects with disabling hearing impairment were obtained from the TDPD database. In this study, data of working-age subjects (age ≥ 18 and <65 years) were selected, and 18,573 subjects were identified and analyzed  (The demographic characteristics and employment status of the participants are presented in < 0.001) .To quantify the domain scores, we determined the scores below 5% of the total scales as the extent of negative effect according to ICF qualifier  (p. 22).Quantified WHODAS 2.0 scores and variables were analyzed using binary logistic regression analysis to determine risk factors for unemployment . The resThis study examined the contributing factors of employment conditions and the relationship between disability and employment status by using WHODAS 2.0 in a large group of individuals with hearing impairment in Taiwan. As previous researchers argued by describing the association of the severity of disability and employment , our stuIndividuals with moderate to severe hearing loss were found more likely to have impaired activities of daily living than those with mild hearing loss or normal hearing ability . In addiOur study was unique in that the disability severity was quantified objectively using WHODAS 2.0, an assessment tool for evaluating the functional impairment of participants in the area of cognition, mobility, self-care, getting along, life activity, and social participation, in addition to perception, because several previous studies have solely focused on the influence of physical factors of impairment and have suggested the correlation between hearing disability and employment outcome. A corresponding assessment for accurately predicting the employment status must be aware of the importance of a holistic range of both symptoms and functional outcomes and comprise multidimensional instruments to make the comparison between studies more feasible, as ICF-based WHODAS 2.0 did . Such a A lower disability status in all the WHODAS 2.0 subdomains was observed in patients with hearing disability having a working status compared with those without. Notably, the domains of mobility, self-care, and life activities pertain to basic activities of daily life and are therefore partially related to the employment status, whereas the functional aspects of understanding and communicating, getting along with people, and social participation require more advanced skills and are necessary for maintaining a job.According to the ICF framework, a person’s functionality or disability represents a dynamic interaction between health conditions and contextual factors, such as environmental and personal factors. The daily activity is affected by a disability in the health condition, which then causes a decline in cognitive functions, self-care, and social participation, forming a vicious cycle . Social The logistic regression analysis in our study revealed that multiple variables, including age, sex, socioeconomic status, urbanization level, residence, education, and severity of impairment, were associated with employment status. This finding was partly supported by a study on the socioeconomic impact of hearing loss in adults in the United States from 1999 to 2002 by the National Health and Nutritional Examination Survey, which revealed that hearing loss was associated with low educational attainment, low income, and unemployment or underemployment . WHO estSex may also influence the effect of hearing loss on socialization. Evidence suggested that men may attribute a lower value to communication than women and may not search for solutions actively. They may more likely withdraw from social activities than struggle to maintain participation. In our study, female subjects with hearing disability were two times less likely to be employed compared with male subjects with hearing disability. By contrast, men with hearing impairment imposed their needs more strongly on their family than women; therefore, women reported a feeling of being less understood by their spouses than men .We found that low education level significantly discriminated employment conditions. According to recent data from East Asian countries, the unemployment rate of highly educated people was above average, and people with low educational level had the highest unemployment rate. These facts may be related to the supply–demand mismatch of the current labor market and the high education system in this area . Furtherp > 0.05) [In this study, the WHODAS 2.0 assessment tool was introduced as a measurement tool for hearing disability. Previous hearing loss-related test tools or questionnaires have caused the problem that the segmental aspects related to hearing loss do not sufficiently explain the correlation between health and environmental factors and functional aspects. Nevertheless, WHODAS 2.0 may not be sufficiently sensitive to detect the quality of life change in hearing-related disability. Ho et al. reported no significant correlation between Hearing Handicap Inventory for Adults or Hearing Handicap Inventory for Elderly Screening and any WHODAS score  .Considering the theoretical framework of the ICF, there seems to be a gap between the actual needs of individuals with hearing loss and the formal support provided by existing public health policies of the government. Therefore, multiple factors need to be addressed when rehabilitation-delivered vocational services and interventional plans for individuals are initiated. Community intervention with social participation should be implemented to maintain a better social interaction ability for social and psychological wellbeing. Running educational campaigns will result in higher rates of employee participation and substantive cost savings, improved rehabilitative service usage, and increased awareness, especially among employers. Employees with hearing impairment should be aware that access to information is imperative to secure workplace adjustments to meet their needs. The barriers towards developing less strenuous working conditions for employees with hearing impairment needs to be recognized and treated accordingly . Early iOur study has the following limitations. The employment statuses were categorized on the basis of whether the subject had a regular job or was jobless. There might be circumstances where some were part-time workers or quit their jobs willingly for taking care of disabled elders or for raising a child at home, the so-called “hidden unemployed”. Future studies can further explore stratification of the job types more specifically to determine the effect of disability severity in patients with hearing loss on their respective jobs. WHODAS assessment was performed on the basis of responses given by subjects or their caregivers. Because some people with severe hearing impairment had limited ability to communicate with the interviewers, their assessment was completed by proxies or using communication card, thereby posing the risk of underestimation of the functional disability. In addition, the WHODAS 2.0 questionnaire only evaluated the disability condition of individuals in the past 30 days and was a single-time-point because we were unable to follow up the return to work processes or detect the ability to maintain a stable vocational status of the patient. Thus, the etiology of hearing impairment could not be identified, and we were unable to discriminate some other possible associated factors, such as hearing loss during current career stage or hearing loss during years in education. Because the DES-2012 evaluation has been used to determine the subsidy for people with disabilities in Taiwan, some participants may purposely make false reports regarding their actual capabilities or performance to receive a greater subsidy. Because WHODAS did not consider some environmental factors, such as the impact of global economic turmoil, social welfare, and insurance policies imposed in different countries or family support and marital status, our study results may be limited to a single country.In all, strategies to mitigate the effect of hearing loss on job security and recruitment must be developed by applying vocational counseling and social education. Effective population-based preventive interventions should be beyond clinical service and traditional areas of diagnosis or treatment and hearing assistive device application. It must focus more on epidemiological surveillance and health promotion to help identify the needs of population, to measure cost and benefits of prevention, to raise awareness regarding the size of problem, to determine program priorities, and to select targets and strategies for prevention. Early identification of problems can be crucial in limiting the level of hearing impairment disabilities with implication for the social security system, leading to effective rehabilitation strategies and policies implementing prioritization of resource allocation.This is the first study to combine physical, social and psychometrical factors in the framework of WHODAS 2.0 that tried to encompass the multi-faceted influence of elements for the impact of hearing impairment on employment. The data in this large population-based study offer comprehensive information on important factors associated with the employment status in people with disabling hearing impairment. The unemployment group had a higher domain-specific and summary scores of WHODAS 2.0. Older age, female sex, lower educational level, institutional residence, rural residence, lower family income, and moderate to severe impairment were associated with the unemployment status. Early identification of hearing impairment people at risk of unemployment can raise awareness of public health for aggressive community and government campaigns to improve their self-confidence, social participation and related psycho-social wellbeing.


For people with hearing loss, the General Practitioner (GP) can play an instrumental role in early detection of hearing loss as well as guiding appropriate and timely choices for addressing hearing concerns. The aim of this study was to generate a conceptual framework for understanding the role of the GP in managing age-related hearing loss.n = 8), adults with hearing loss (n = 22), and professionals working with GPs (n = 5), in Australia. Participants generated statements describing the role of the GP in managing age-related hearing loss, and then grouped the statements to identify key themes, via an online portal.Concept mapping techniques were used to gather the perspectives of GPs (Ninety-eight items describing the role of the GP in managing age-related hearing loss were identified across six concepts: 1) Determine - Diagnose - Discuss, 2) Ask - Assess - Act, 3) Know - Refer - Coordinate, 4) Inform - Advise - Partner, 5) Educate - Strategise - Encourage, 6) Reassure - Support - Empower.The role of the GP in managing age-related hearing loss is multifaceted and requires partnership that motivates and empowers patients’ to overcome their hearing concerns. Enlisting the help of Practice Nurses, Practice Managers and local audiologists could help GPs improve their hearing loss detection and intervention rates. Hearing connects us with our environment, providing an awareness of our surroundings, warning for potential dangers, and an avenue for social connection. However, the sense of hearing can be taken for granted, with hearing loss often viewed as an unfortunate but benign side effect of aging. The notion of “age appropriate hearing loss” disregards the devastating impacts that unmanaged hearing loss can have on the many facets of an individual’s life , 2. HearResearch has highlighted the influential role of support from others on hearing help-seeking, including significant others (family and friends) –14 as weFor people with hearing loss, the GP can play an instrumental role in guiding appropriate and timely choices for addressing hearing concerns. A population-based consumer survey in the USA reported that people with hearing loss are five times more likely to seek a hearing solution when their GP gives a positive recommendation for hearing healthcare . The reaThis study used concept mapping techniques to develop a framework for understanding the perceived role of the GP in managing age-related hearing loss. Concept mapping is a semi-qualitative approach wherein participants put forward statements that described their perceptions or experiences related to a topic of interest,  in this . Professionals that provide training to and/or work with GPs were recruited via GPs involved in this study, through the Australian Primary Healthcare Nurses Australia (APNA), and through the Australian Association of Practice Management (AAPM).Three stakeholder groups were identified and recruited for this study: GPs currently working in Australia; adults with hearing loss who had sought help from a hearing clinic; and professionals who provide training for or work with GPs in Australia, including but not limited to Practice Managers, Practice Nurses, and University lecturers. GPs were recruited via the Victorian Primary Care Practice-based Research Network (VicReN ), the RoThis project was conducted under the oversight of the University of Melbourne Human Research Ethics Committee, 1,851,579.2.Participants contributed to two online data collection sessions using Concept Systems Inc. software : one BraParticipants were asked to provide statements in response to the open-ended question “What should the role of the GP be in managing age-related hearing loss?”, and were provided with the prompt “In my opinion, the role and responsibility of GPs in managing age-related hearing loss is…”. Participants were encouraged to brainstorm as many responses as possible, entering them into the online system. All statements were available for other participants to see so that they could build on each other’s ideas. Participants were not able to change or comment directly on others’ statements, only contribute new statements. Participants were not identifiable to each other. The brainstorming session was accessible for 6 weeks, after which the research team reviewed all of the responses to eliminate those that were irrelevant (not strictly answering the research question), and edited the remainder for clarity where required. This final list of statements was then used for the grouping session.Approximately 2 weeks after completion of the brainstorming session, participants were asked to log into the portal again to complete the grouping session. On this occasion they were presented with the list of edited statements and asked to group them in a way that made sense to them. Participants were provided with the following instructions: (a) there was no right or wrong way to group the statements, (b) a statement could be put in its own group if it was unrelated to the other statements or if it stood alone as a unique statement, and (c) they should not have a “Miscellaneous” or “Other” group , 31. ParData analysis was conducted using Concept Systems software  and IBM A split-half reliability measure was conducted to evaluate the validity of the final concept map, applying the Spearman-Brown Prophecy Formula correction . A correThirty-five participants completed the brainstorming activity: eight GPs; 22 adults with hearing loss; and five professionals working with GPs. This sample meets the recommendations of at least 20 people for a concept mapping brainstorming activity . ParticiDuring the brainstorming activity four participants expressed opinions that the GP does not have a role in managing age-related hearing loss, in that people liaise directly with an audiologist for their hearing services and do not involve their GP. Statements of this effect were excluded from the study as they did not directly answer the research question “What should the role of the GP be in managing age-related hearing loss?”Editing the remaining raw brainstormed statements resulted in a final list of 98 statements used in the grouping task. The individual statements described both biomedical and person-centred approaches to patient care. Biomedical actions included detection, diagnosis, treatment and referral. Person-centred actions included listening, supporting, motivating and reassuring.The number of groups created by participants ranged from four to 21 . The research team  determined that the six-cluster configuration most appropriately represented the participants’ brainstorming and grouping data. This six-cluster concept map .The two concepts The purpose of this study was to investigate the perceived role of the GP in managing age-related hearing loss, from the perspective of GPs, adults with hearing loss, and professionals working with GPs. At a time when GPs are considered not just medical specialists, but specialist in life, it is unsurprising that GPs are perceived to play a role in the biomedical and psychosocial aspects of hearing loss.Hearing loss is described as an invisible disability, as people do not often recognise hearing loss in themselves. As a result, many adults live for years, or even decades with the psychosocial impacts of unmanaged hearing loss . ParticiParticipants in this study recommended the incorporation of routine hearing screening programs in general practice. Implementing hearing screening programs targeting older adults has been shown to increase the detection rate for hearing loss, , 38 and One potential option to support GPs in prioritising hearing discussions might be the redistribution of tasks within the primary care setting. Over time, the work of the GP has shifted towards the management of chronic disease, and general practice itself has become organised through increasingly complex groups of doctors, Practice Nurses, administrative managers and support staff . Consist‘partner’ with their patients, for example: developing an understanding of their experience of hearing loss, encouraging help-seeking, providing education and training on hearing loss management (including ear wax management and communication training), promoting compliance with intervention options (including hearing aid use), and working with health professionals to take a multidisciplinary approach to patient care. The rising number of people living with chronic (and multiple) health conditions requires GPs to be patient-focussed, to seek understanding of what individual patients need from health and social services, and to provide tailored support, to reduce dependency and improve quality of life [Patient-centred care is central to the mission of healthcare, especially self-management of chronic disease . In this of life , 50. Emp of life . This neKnow - Refer - Coordinate concept. The statements contained within this theme described not only the process of referral to specialist audiology services, but the importance of the GP having knowledge of who they are referring to, and to refer to reputable hearing services. A comparable scenario is a 2015 enquiry into mental health management in the primary care setting explored the barriers and facilitators to GP referral for specialist mental health services [The importance of multidisciplinary care and the GP’s role in coordinating this was particularly highlighted through the services . Improviservices  and despservices  additionKnow - Refer - Coordinate concept also described the importance for the GP to have an understanding of the “next steps”, and to assist and encourage the patient through the referral process. The notion of ‘warm’ referral has started to emerge in the medical literature and practice [The practice . TraditiParticipants self-selected for the study, and although the sample sizes were sufficient for concept mapping procedures, data from only 35 participants may have biased the content of the statements captured. Furthermore, participants described their experiences within the Australian context of service delivery, potentially biasing the findings. Future research could also explore the experience of non-help-seekers to better understand the barriers to seeking support for hearing loss in the General Practice setting.The perceived role of the GP in managing age-related hearing loss is multifaceted and includes detection and diagnosis, discussion and empowerment, as well as referral and ongoing support. For adults with hearing loss, the GP can play an instrumental role in the early identification of hearing loss, guiding appropriate and timely choices for addressing hearing concerns, and providing partnership that motivates and empowers patients’ to overcome their hearing concerns, and the psychosocial impacts that develop due to untreated hearing loss. There is scope to optimise how this occurs in GP clinical practice.