WP1: PLUS-Auditory Training The goal of this experimental study is to better understand how task difficulty affects on-task learning thresholds and generalised benefits in two PLUS auditory training tasks involving perceptual and cognitive learning in adults aged 18+ (no upper age limit) with listening difficulties. The main question it aims to answer is: * Does adjusting task difficulty in PLUS, by manipulating the perceptual and cognitive demands of the phonemic discrimination and competing speech tasks, affect on-task learning thresholds and off-task performance in adults with listening difficulties? Researchers will compare the two experimental arms (easy/hard) to see whether adjusting task difficulty influences on-task learning thresholds and off-task performance. Participants will: * Be randomly assigned to one of two training programs (phonemic discrimination or competing speech) within the two experimental arms (easy/hard); * Perform training for a minimum of 30 minutes per day, 5 days per week, for two weeks (total 10 training sessions, 5 hours of training); * Complete pre- and post- training assessments to measure on-task learning performance and change in performance for untrained measures of speech perception, cognition and self-reported outcomes. WP2: Post-Training Focus Groups The goal of this observational study is to gain in-depth qualitative insights into participants' motivations, experiences of task difficulty, and perceived benefits across the PLUS-AT training groups in adults aged 18+ (no upper age limit) with listening difficulties. The main question it aims to answer is: * How do participants describe their experiences and perceptions of PLUS-AT, particularly regarding task difficulty and self-perceived changes in listening, hearing, thinking, and quality of life? Researchers will explore participant experiences across the two experimental arms (easy/hard) to determine whether motivations for seeking auditory training, knowledge and beliefs about auditory training, attitudes toward PLUS-AT difficulty, and self-perceived changes in listening, hearing, thinking, and quality of life differ. A subset of participants (n = 20) will: * Be invited from WP1 to join one of four online focus groups (60-90 minutes via Microsoft Teams); * Attend the focus group corresponding to their assigned training program (phonemic discrimination or competing-speech) within the two experimental arms (easy/hard); * Share their experiences of completing PLUS-AT.
Hearing loss (HL) is a progressive, long-term condition without cure, affecting 18 million people in the UK, which is approximately one in three adults. Globally, HL is the third leading cause of years lived with disability and has major individual, societal, and economic consequences. When unmanaged, HL can lead to communication difficulties, social withdrawal, depression, reduced quality of life, accelerated cognitive decline, and increased dementia risk. A key challenge reported by people with HL is the difficulty hearing speech in noisy environments, which often persists even when hearing aids (HAs) are used. HAs are the primary management option for HL, but uptake and consistent use is low. Of the 6.7 million people in the UK who could benefit from them, many people do not seek help for their hearing difficulties, and only around 2 million have hearing aids, with non-use estimated to range from 3 to 24%. Therefore, it is essential to develop interventions that can work either as a precursor to or adjacent with HAs to effectively address listening and hearing difficulties. Auditory training (AT) delivered via internet-accessible devices such as phones or laptops, can be used before or alongside hearing devices such as HAs. As a low-cost intervention, AT supports the self-management of HL and listening difficulties and can be tailored to individual needs. Training itself involves focused listening exercises designed to improve everyday listening, especially in noise. Research shows that AT can improve speech perception throughout an adult's lifespan. It can help individuals improve their ability to distinguish speech in challenging environments like restaurants or family gatherings. PLUS is a web-based app, standing for Practice Listening and Understanding Speech, developed at the University of Nottingham as an auditory-cognitive training programme. It builds on a decade of research indicating that domain-general improvements in cognitive processing, rather than auditory processing alone, drive the transfer of learning (generalised benefits) to untrained stimuli or tasks. Designed as a cognitively demanding speech training programme, PLUS aims to maximise the transfer of learning to real-world benefits for people with hearing loss. The auditory-cognitive approach was adopted since speech-based tasks are essential for maintaining user motivation and ensuring the training is perceived as relevant to hearing. PLUS has many different settings which changes the task difficulty and influences the level of perceptual and cognitive demand on the learner. It is not known which settings are the most optimal for maximal on-task learning and transfer of learning to everyday listening. The study outlined in this protocol seeks to understand how task difficulty in PLUS affects on-task learning thresholds and generalised benefits in populations with listening difficulties as a first step towards creating an optimal AT intervention for people with HL and self-reported listening difficulties.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
SINGLE
Enrollment
120
PLUS is a web-based auditory training platform with two adaptive auditory-cognitive training tasks designed to improve listening and communication. Phonemic Discrimination: Phonemes are sounds (e.g. /ba/ vs /da/) that make words different (e.g. "bad" vs "dad"). Participants hear three sounds (e.g., /ba/, /ba/, /da/) from sound pairs (e.g. /ba/ and /da/), and must identify the sound that's different (/da/). Competing Speech: Two talkers produce similar sentences that differ by keywords. Participants are asked to focus on one talker (cued by a target visible on screen) while ignoring a second talker and report two keywords from a list of all possible options.
NIHR Nottingham Biomedical Research Centre
Nottingham, Nottinghamshire, United Kingdom
RECRUITING(Adapted) Coordinate Response Measure (CRM)
This test measures how well participants understand target speech when another talker is present. Two sentences are played at the same time: a female talker (target) and a male talker (distracter). Sentences follow the format 'show the \[animal\] where the \[colour\] \[number\] is', using a fixed target animal (dog) and limited sets of colours and numbers. The distractor never says 'dog' and always names a different animal. Participants identify the colour and number spoken by the female talker while ignoring the male talker, responding via computer or touchscreen. Task difficulty is varied by adjusting the signal to noise ratio (SNR) between target and distracter using an adaptive one up/one down staircase to estimate the speech reception threshold (50% correct). Each run ends after a set number of reversals or trials. Participants complete four runs, with the first as practice. Lower thresholds indicate better performance.
Time frame: Week 1, Week 3
Practice Listening and Understanding Speech (PLUS) Auditory Training
Performance on the trained PLUS tasks (phonemic discrimination and competing speech) will be measured across the 10 training sessions. Each task uses an adaptive procedure to generate a threshold that reflects the level at which participants correctly identify the target speech information 50% of the time. For phonemic discrimination, this is the smallest contrast between speech sounds that can be reliably distinguished. For competing speech, this is the signal-to-noise ratio needed to understand the target talker. Thresholds from each session indicate learning and changes in trained task performance.
Time frame: Week 1, Week 2
Letter N-back
This is a 2-back designed to assess how well participants can keep track of and update information in WM. Letters (A-Z) are presented one at a time, and participants indicate whether the current letter matches the one shown two positions earlier. Each block contains 120 trials: 30 targets (2-back matches) and 90 non-targets. The first two trials are always non-targets. Two distinct versions of the task, each with a different predefined letter sequence, are used to avoid repetition; participants complete one version at pre-training and the alternate version at post-training. Each letter is displayed for 1000 ms within a 2500-ms trial window. Responses are made via keyboard or touchscreen. Accuracy is calculated as correct identification of targets and correct rejection of non-targets, with higher scores indicating better working-memory updating.
Time frame: Week 1, Week 3
Flanker Task
This task measures how well participants respond to a central target while ignoring surrounding distractor items. On each trial, a row of fish appears and participants indicate the direction of the middle fish. One practice block (4 trials) and one test block (12 trials) are completed. Each trial begins with a fixation cross (500 ms in practice; 400, 800, or 1200 ms in test trials). Distractor fish then appear for 1150 ms, with the target fish appearing 200 ms later and remaining visible for 750 ms. Participants respond using 'Q'/'P' keys or touchscreen buttons. Feedback is shown for 500 ms. Trials are easier when distractors point the same way as the target and harder when they point the opposite way. Performance is based on response speed and accuracy, with higher scores indicating better ability to manage distracting information.
Time frame: Week 1, Week 3
Dual-task of Listening and Memory
Participants complete two tasks at the same time: remembering a sequence of five visually presented digits and repeating spoken words in background noise. Each trial begins with a five-digit string shown for five seconds. Participants then hear five monosyllabic words (AB Isophonemic lists) presented in 0 dB ICRA multitalker babble. Words appear one per screen, beginning 250 ms after screen onset, with the noise continuing for 3000 ms. After typing each word, the next screen appears. Once all five words are entered, participants recall the original five digits. There are four trials in total, with trial order randomised. Scores range from 0-20 for correctly repeated words and 0-20 for correctly recalled digits. Two distinct digit-word lists are used: List 1 is completed in Week 1 (pre-training) and List 2 in Week 2 (post-training).
Time frame: Week 1, Week 3
Wisconsin Card Sorting Test (WCST)
This test is designed to assess how well participants can switch their thinking or adapt to new rules and situations. Participants are shown cards that vary in colour, shape, and number and are asked to match a target card to one of four cards displayed above it. The matching rule may relate to colour, shape, or number, but the rule is not given and must be inferred from feedback. Correct responses trigger a green thumbs-up icon and incorrect responses a grey thumbs-down icon, shown for 500 ms. Cards remain on screen until a response is made and feedback is displayed. The rule changes periodically, requiring participants to adjust their choices based on the feedback they receive. Performance is scored by the number of correct sorts and the frequency of perseverative errors, defined as continuing to use a previous rule despite negative feedback. Higher scores indicate better performance on the task.
Time frame: Week 1, Week 3
Glasgow Hearing Aid Benefit Profile (GHABP), Part A
Participants are asked to rate their perceived hearing disability (difficulty) and the associated handicap (importance of that difficulty) across four standard listening situations: conversation with one person in quiet, conversation in noise, group conversation, and TV listening. Each is rated on a five-point scale (1 = no difficulty / no importance, 5 = cannot manage at all / very important). Separate mean scores are calculated for Disability and Handicap and expressed as percentages, with higher scores reflecting greater perceived difficulty or handicap. Participants who wear a hearing aid(s) will be asked to complete this questionnaire based on how they hear with their hearing aid(s).
Time frame: Week 1, Week 3
Revised Hearing Handicap Inventory (RHHI)
This is a validated self-report instrument designed to measure the perceived psychosocial impact of hearing loss on an individual's daily functioning. The questionnaire comprises 18 items addressing various hearing-related difficulties and emotional responses. Participants respond to each item using a three-point scale: "Yes," "Sometimes," or "No," which are scored 4, 2, and 0 points respectively. The total score ranges from 0 to 72, with higher scores reflecting greater self-perceived hearing handicap. This scoring approach enables the quantification of the degree to which hearing loss affects communication and quality of life, facilitating both clinical assessment and research measurement of hearing-related disability. Participants who wear a hearing aid(s) will be asked to complete this questionnaire based on how they hear with their hearing aid(s).
Time frame: Week 1, Week 3
Social Participation Restrictions Questionnaire (SPaRQ)
The Social Participation Restrictions Questionnaire (SPaRQ) is a 19-item, self-report instrument developed to assess the impact of hearing loss on social participation in adults. It comprises two subscales: the 9-item 'Social Behaviors' subscale, which evaluates difficulties in performing social actions due to hearing loss, and the 10-item 'Social Perceptions' subscale, which assesses negative thoughts and feelings experienced in social contexts related to hearing loss. Participants respond to each item using a five-point Likert scale ranging from 'Strongly disagree' to 'Strongly agree'. The total score is the sum of all item scores, with higher scores indicating greater perceived restrictions in social participation. Participants who wear a hearing aid(s) will be asked to complete this questionnaire based on how they hear with their hearing aid(s).
Time frame: Week 1, Week 3
Digit Triplets Test
Participants hear triplets of monosyllabic digits (0-9, excluding 7) presented against steady speech-shaped noise in a version of the task rebuilt by the research team in Gorilla. An adaptive 2-up/1-down procedure adjusts the signal-to-noise ratio (SNR) to estimate the speech reception threshold (SRT). The test begins with two fixed trials at 0 dB SNR, then uses step sizes of 8 dB at the first reversal, 4 dB at the second, and 2 dB for the remaining reversals. Exactly 40 trials are administered, with SNRs ranging from -10 to +15 dB. The final SRT is calculated as the average SNR across the last eight reversals, with more negative values indicating better speech-in-noise perception. A cut-off of -5.5 dB SNR or higher is used to identify participants with listening difficulties.
Time frame: Week 1
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