Knowledge, attitude, and practice toward cochlear implants among deaf patients who received cochlear implants

Despite the growing use of cochlear implants in deaf patients, there is a lack of data on their knowledge, attitude, and practice (KAP) toward cochlear implants. This study aimed to investigate the KAP toward cochlear implants among deaf patients who received cochlear implants. A web-based cross-sectional study was conducted between August 2022 and December 2022 among deaf patients who had received cochlear implants. A self-administered questionnaire was used to collect demographic characteristics and KAP scores. A total of 526 participants were enrolled; 54.18% were female, 65.40% were above 60 years old, and 61.03% were surveyed at less than 3 years after implantation. The mean knowledge, attitude, and practice scores were 8.15 ± 2.18 (possible range: 0–10), 43.63 ± 6.98 (possible range: 12–60), and 41.11 ± 7.42 (possible range: 11–55), respectively, indicating good knowledge, moderate attitude and practice. Multivariable logistic regression analysis showed that attitude [odd ratio (OR) = 1.24, 95% confidence interval (CI) 1.18–1.29, P < 0.001] and unemployment (OR = 0.33, 95% CI 0.17–0.63, P = 0.001) were independently associated with practice. Path analysis showed that knowledge directly influenced attitude (β = 0.93, 95% CI 0.61–1.19, P < 0.001), attitude directly influenced practice (β = 0.53, 95% CI 0.46–0.61, P < 0.001), and knowledge directly (β = 0.77, 95% CI 0.53–1.01, P < 0.001) and indirectly (β = 0.50, 95% CI 0.34–0.66, P < 0.001) influenced practice. Deaf patients who received cochlear implants showed good knowledge, moderate attitude and practice toward cochlear implants. Knowledge should be strengthened to improve attitude and practice toward cochlear implants, which could translate into realistic expectations toward cochlear implants devices and proper care and maintenance.


Procedures
According to the available guidelines for cochlear implants 13,14 , the self-administered questionnaire was designed by the authors and modified according to the comments of four experts with experience in cochlear implants for multiple years.The pre-test (90 copies) was performed and showed a Cronbach's α of 0.895 and a Kaiser-Meyer-Olkin (KMO) of 0.781, showing high intrinsic consistency.
The final questionnaire included demographic characteristics, and knowledge, attitude, and practice dimensions.The knowledge dimension consisted of 10 items.One point was awarded for correct answers and 0 for incorrect answers or unclear.The total score ranged from 0 to 10 points.The attitude dimension consisted of 12 items scored using a Likert 5-point scale, ranging from very positive (5 points) to very negative (1 point).The total score ranged from 12 to 60 points.The practice dimension consisted of 15 items, of which 11 of them were scored using a Likert five-point scale, ranging from always (5 points) to never (1 point).The total score ranged from 11 to 55 points.A score of more than 80% of the total score was considered "good", 60%-80% was considered "moderate", and less than 60% was considered "poor" 15 .

Questionnaire distribution and quality control
Patients who could be contacted by the researchers and research assistants involved in the study were included through a convenience sampling method.Prior to the study, four research assistants (including one junior physician from the department) were trained online on the methods and precautions for collecting questionnaires and emphasized the importance of authenticity.Online questionnaires were sent to patients via WeChat and administered on the Wenjuanxin platform (https:// www.wjx.cn), which generated quick response (QR) codes.Participants logged in and filled out the questionnaire by scanning the QR code.In order to ensure data quality and completeness, each IP address was restricted to one submission, and all questionnaire items were made mandatory.Participants were assured of anonymity while completing the questionnaires.The data collection methods primarily included offline questionnaire administration (when the patients came to the hospital for follow-up or device adjustment), telephone interviews, and online completion through WeChat contact.For offline questionnaire administration, the research assistants helped the patients with the scanning QR code and instructed them how to complete the questionnaire.The research assistants could also hand paper questionnaires to the patients with limited access to technology.Telephone interviews were conducted by a research assistant who first explained the purpose, methodology, and relevant study instructions to the patients and invited them to complete the questionnaire over the phone.Online completion through WeChat contact was the preferred method when possible.The participants had to possess a valid and reliable WeChat ID for logging in, but the WeChat ID was not associated with the questionnaire, and the survey was conducted anonymously.After questionnaire collection, the researchers checked all questionnaires for completeness.

Statistical analyses
The sample size was calculated using the formula for cross-sectional studies: .96 when α = 0.05, the assumed degree of variability of p = 0.5 maximizes the required sample size, and δ is an admissible error (which was 5% here).The theoretical sample size was 480, which includes an extra 20% to allow for subjects lost during the study.
The statistical analysis software was Stata 17.0 (Stata Corporation, College Station, TX, USA).The continuous data were expressed as mean ± standard deviation (SD) and analyzed using ANOVA.The categorical data were expressed as n (%) and analyzed using the chi-square test.Pearson's correlation was used to analyze the correlations between the KAP scores.Univariable and multivariable logistic regression analyses were performed for the practice scores.The variables with P < 0.05 in the univariable analyses were included in the multivariable analyses; the cut-off for the practice scores was 70% of the data distribution.Path analysis was used to test the following hypotheses: (1) knowledge had impacts on attitude; (2) knowledge had impacts on practice; (3) attitude had impacts on practice.Two-sided P-values < 0.05 were considered statistically significant.

Ethics approval and consent to participate
The study was carried out after the protocol was approved by the Institutional Review Board of The Second People's Hospital of Hefei Clinical Experiment Ethics Committee.I confirm that all methods were performed in accordance with the relevant guidelines.All procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Characteristics of the participants
In this study, 526 participants were enrolled, with the majority residing in Anhui (Supplementary Fig. 1).Among the 526 participants, 54.18% were females, 65.40% were aged over 60 years old, 61.03% had been implanted within 3 years before participation, 61.79% lived in urban areas, 67.30% were married, and 98.48% were covered by medical insurance (Table 1).

Knowledge
The mean knowledge score was 8.15 ± 2.18 (possible range: 0-10), indicating good knowledge.Higher knowledge scores were observed in non-urban dwellers (P < 0.001), those with higher education (P < 0.001), and those with employment, retired, or freelancing (P < 0.001).There were no significant differences in the knowledge scores between different age (P = 0.217) or status of implant use (P = 0.055) (Table 1).The item with the highest score was K4 ("Cochlear implant devices include implants in the body and speech processors out of the body", 93.54%), while the item with the lowest rate of correct answers was K7 ("There is no need to carry out scientific and effective auditory speech rehabilitation training after surgery, and speech comprehension, speech expression and language use ability will be naturally restored", 18.44%) (Table 2).

Attitude
The mean attitude score was 43.63 ± 6.98 (possible range: 12-60), indicating moderate attitude.There were significant differences in attitude between different residence (P = 0.016), education level (P = 0.003), income (P = 0.046), and medical insurance (P < 0.05) (Table 1).Table 2 presents the distribution of the attitude.The extremely positive/positive rates (or very negative/negative for the negative items) were 67.68% for "Postoperatively, how satisfied are you with the following health-related quality of life: A1: physiological function", 37.83% for "Postoperatively, how satisfied are you with the following health-related quality of life: A1.2: advanced sound perception", 55.89 for "Postoperatively, how satisfied are you with the following health-related quality of life: A1.3: speech ability", 57.41% for "A2: Mental function: self-confidence", 72.81% for "A3.1:Social function: activity", 46.01%for "A3.2:Social function: social interaction", 50.95% for "A4: Wearing an electronic cochlear makes me feel inferior", 83.27% for "A5: I would like to wear a cochlear implant every day", 41.45% for "A6: When wearing cochlear electronics, people around me often look sideways, which makes me feel embarrassed", 72.25% for "A7: After the operation, my family and friends took great care of me, making me quickly adapt to wearing cochlear electronics", 39.55% for "A8: Wearing cochlear electronics restricts my daily activities and makes me feel very inconvenient", and 46.39% for "A9: Wearing an electronic cochlear should pay attention to the daily environment, which restricts my travel".

Discussion
This study revealed that the patients had good knowledge and moderate attitude and practice toward cochlear implants.A good attitude was found to have a positive impact on practice.Specific points should be improved and emphasized when teaching the patients about the implants, specifically regarding the care and capabilities of the device.A previous study in India showed that the parents of children scheduled for cochlear implantation had high KAP regarding cochlear implants 12 , which is unsurprising since it is an invasive procedure with possible complications, and the parents want to be well-informed to ensure the best outcomes for their children.On the other hand, a study in Saudi Arabia showed lower KAP in parents of children with hearing loss 16 .A previous study in patients with hearing loss showed poor knowledge about the eligibility criteria for receiving cochlear implants 17 .
In the present study, the participants were surveyed after implantation and showed good knowledge and active practice but a lower attitude.Still, two important knowledge points would warrant improvements.Indeed, the K5 ("The external part of the cochlear implant is not affected by the surrounding temperature, humidity, electromagnetic and physical forces") and K7 ("There is no need to carry out scientific and effective auditory speech rehabilitation training after surgery, and speech comprehension, speech expression and language use ability will be naturally restored") items had low scores.Knowing that the external part is fragile and should be cared for appropriately is essential for ensuring the device's longevity and avoiding medical expenses due to device replacement.In addition, as the devices evolve, replacement external parts might no longer be compatible with the internal parts, necessitating reoperation.Hence, it is of the utmost importance to stress the good care of the device 18,19 .Not knowing that auditory rehabilitation is necessary after receiving cochlear implants has been reported before and appears to be a common misconception about cochlear implants 20 .Indeed, cochlear implants allow some kind of sound perception, but they do not restore natural hearing 20 .Hence, patients who have never heard will simply learn to hear with the device after implantation.On the other hand, people who have heard naturally for a part of their lives have to relearn how to hear using the novel signals sent by the device 20 .In addition, properly teaching the patients how to take care of their implants should help prevent device damage and medical expenses for replacements.
Importantly, physicians are among the primary sources of reliable medical information for the patients and the population.Still, previous studies showed that the KAP of cochlear implants of otolaryngology and nonotolaryngology physicians could be improved [21][22][23][24] .A study in speech and language therapists reported similar results 25 .A study in the United Kingdom suggested that although audiologists had a good knowledge of cochlear implants, they lacked the confidence to discuss the option with their patients 26 .Hence, the literature suggests that the KAP of physicians could be improved, which could help relay precise information to the patients since physicians are often the primary source of reliable health knowledge.The physicians were not surveyed in the present study, and their KAP in the study area remains unknown.Future studies could address that issue and see how their KAP could be improved.www.nature.com/scientificreports/ The attitude questions covered areas about satisfaction with the device and perceived functions related to self-confidence, social function, social perception, and activities of daily living.In the present study, the lower attitude scores were mainly related to hearing expectations relative to the device (e.g., hearing sounds in a noisy environment) and social situations (feeling of inferiority and shyness of being observed in public).Indeed, patients might have misconceptions about what the cochlear implants can do 27,28 .Zeitler & Holcomb 27 reported five common myths about cochlear implants, the fourth myth being that cochlear implants can restore hearing to "normal", which is false.For now, the available devices transmit all sounds equally and do not discriminate between background noise and targeted sounds 27,28 .Devices that suppress background noise are being researched but are not yet commercially available 29 .In addition, the device's external part is obvious, cannot be hidden, and will bring attention to the wearer.Therefore, based on the present study and the known myths about cochlear implants, it appears important to manage the patient's expectations when discussing the management options for deafness.Therefore, the moderate attitude scores indicate that managing the expectations of the patients should help the patient's quality of life after surgery and have a better attitude after the surgery.
This study showed that attitude was independently associated with good practice.The SEM analyses also showed that knowledge directly influenced attitude and practice and indirectly influenced practice, and attitude directly influenced practice.Therefore, based on the KAP theory, cultivating a favorable attitude would be conducive to improving the practice 10,11 , including proper cochlear implant care and maintenance.In addition, Cochlear implants are delicate and expensive devices that require proper care.In the present study, only four participants (< 1%) had deprecated cochlear devices, indicating that most participants were taking proper care of their implants.The exact reasons for taking good care of their devices were not explored in the present study but could be related to the fear of additional medical expenses and living without a cochlear implant.Besides hearing, the improvements in tinnitus and vertigo observed in the present study could be another reason for taking good care of the devices.Indeed, it has been reported that cochlear implants can help reduce tinnitus and vertigo [30][31][32] .Auditory deprivation is thought to be a major cause of tinnitus 33 .Therefore, restoring hearing using cochlear implants has decreased tinnitus 34 , as reported in the present study.The mechanisms of vertigo improvement are still unknown, but vertigo improvement after cochlear implants has been reported 30,35,36 , as also observed here.
A strength of the present study is the enrollment of a relatively large sample of patients with cochlear implants.It was possible because the authors' hospital is a tertiary center specializing in such devices.Hence, since the study examined the KAP of the hospital's population, the results will be directly translated to improve the conditions of the patients.
Nevertheless, this study had limitations.The sample size was relatively small and from a limited geographical area.The study included participants mainly from Anhui province in China, which may restrict the applicability of the findings to other regions or countries with different healthcare systems or patient populations.The questionnaire was designed by the authors and influenced by the local guidelines and practice, limiting generalizability.Furthermore, it was a self-administered questionnaire, introducing potential response bias.In addition, the understanding of the questions can influence the answers.The questions were revised by the experts, who could suggest different formulations, but the understanding of the question was not tested.The use of self-administered questionnaires relies on participants accurately understanding and responding to the questions, which may lead to response bias or misinterpretation of the items.KAP surveys are only a picture of a specific subject at a specific time 10,11 .There is a potential selection bias due to the convenience sampling method.Indeed, convenience sampling may introduce bias as participants were selected based on their availability and contactability by the researchers, potentially limiting the generalizability of the results.Finally, as offline investigations could be influenced by researchers' interpretations of information, there is a potential for social desirability bias.Still, the results can provide guidance for teaching and training activities and can be used as a comparator to evaluate the success of the implemented methods in the future.

Conclusion
In conclusion, the patients who received a cochlear implant show good knowledge, moderate attitude, and proactive practice toward cochlear implants.It could be advantageous for healthcare professionals to educate patients about the potential benefits and drawbacks of cochlear implants and proper usage and care.Future studies should examine educational interventions that could be implemented to improve the KAP of patients toward cochlear implants.

Table 1 .
Baseline characteristics and KAP scores.a refers to the comparison of knowledge scores between different demographic characteristics; b refers to the comparison of attitude scores between different demographic characteristics; c refers to the comparison of practice scores between different demographic characteristics.

Table 3 .
18ivariable and multivariable logistic regression analyses of practice.unemploymentandotherwork status (i.e., other than employment, retired, self-employed, and farmer) were associated with poor practice toward cochlear implants.It could be due to financial or insurance reasons, little time available, and improper/difficult access to healthcare resources.Money and a lack of insurance are the main reasons preventing access to cochlear implants in the United States of America18.Programs should be implemented to provide access to cochlear implants to anyone eligible.

Table 4 .
The direct and indirect estimates of SEM.