Chapter 3 90 were also confirmed, but it must be noted that the association with BHI was weak and non-significant. Although employees with hearing loss have been shown to report higher LE compared to those with normal hearing (Kramer et al., 2006), our results do not indicate that differences in the degree of hearing loss can explain the severity of the LE. An explanation is that the degree of hearing loss was moderate in the majority of the study participants. The differences in degree of hearing loss were thus relatively small. Also, the degree of limitations does not only depend on the degree of hearing loss, but also on other factors, such as the auditory work demands or the personal adjustments (Van der Hoek-Snieders et al., 2020). Lastly, the association between the degree of hearing loss and LE would possibly be higher when the degree of hearing loss is measured with a performance test in an aided listening situation. This should be assessed by future research. Analysis of the questionnaire data before and after the aural rehabilitation revealed significant improvements, both in NFR and in LE. Our study is the first that demonstrates that the NFR of employees with hearing loss can be improved by aural rehabilitation. In previous studies, no significant improvement in NFR was reported after aural rehabilitation (Gussenhoven et al., 2017; Van Leeuwen et al., 2021). An explanation might be that the population of Gussenhoven et al. (2017) included a relatively high number of participants with low NFR, which might have resulted in a floor effect in their study. The mean NFR hardly differs between our study (mean = 50.1, SD = 21.6) and the study of Gussenhoven et al. (2017) (mean = 46, SD = 31). However, employees presented substantially more often with low NFR (NFR score below 20) in the latter study. Specifically, low NFR was found in 8 percent of participants in our study and in 26 percent of the participants in the study of Gussenhoven et al. (2017). The number of employees with low NFR is not mentioned by Van Leeuwen et al. (2021). Differences in follow-up time might also explain the finding that we found a significant reduction in NFR in contrast to earlier studies. Our follow-up time was three months, whereas van Leeuwen et al. (2021) had a follow-up time of five years. It could therefore be the case that NFR decreases directly after the aural rehabilitation, but increases again after some time. A similar pattern was observed in a recent study, including patients that received their first hearing aid (Holman et al., 2021b). Although listening related fatigue decreased from before fitting to six months post-fitting for some of the included patients, no change was observed in long-term general fatigue. This pattern was however not concluded
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