The critical element in successful hearing remediation
The hearing rehabilitation process can be seen as a joint decision-making process that usually requires patients to adapt or change their behavior in order to effectively use hearing aids, implement new communications strategies, or even manage their balance problems.
There are a number of theories to explain how individuals accept their health diagnoses and decide to engage in treatment. The Health Belief Model (HBM),1 developed in the 1950s by social psychologist Godfrey Hochbaum, is one of the most commonly used theories in health promotion and health education. Used by scientists to try to predict health behaviors, it continues to be relevant to health care in the 21st century.
The HBM focuses on the role of personal beliefs in taking action regarding health and is particularly relevant to hearing loss and the rehabilitative process. The HBM theory states that “an individual’s behavior can be predicted based upon certain issues…that an individual may consider when making a decision about a particular behavior concerning their health.”2 The HBM suggests that the probability an individual will take action is based on a careful weighing of the perceived benefits of the action and the perceived barriers to accomplishing that action. In brief, the attitudes and beliefs of people are core components of managing change.
At the recent Ida Institute seminar, Living Well with Hearing Loss, Patricia McCarthy, PhD, professor of audiology at Rush University in Chicago, shared typical HBM model constructs. They include a patient’s perceived susceptibility or chances of getting a condition, whether high or low, and the individual’s opinion of how serious a condition and its consequences might be for the individual. These constructs are further influenced by the perceived benefits of the behavior change and the individual’s opinion of the tangible and psychological costs of following the health care recommendations. Other influencing factors include events, people, or things that cause the individual to act and self-efficacy: the confidence that the person has in his/her own ability to take action. Self-efficacy is a patient’s “I can” or “I cannot” belief—a personal judgment about being able to perform specific tasks.
Self-efficacy is an important part of the HBM when looking at long-term health behaviors and rehabilitation. Self-efficacy involves self-confidence to execute a behavior change and the belief that one will be successful in dealing with the disorders or disease.3 It is a domain-specific belief. A person may have high self-efficacy for one task and low self-efficacy for another task.4,5 Importantly, self-efficacy helps to determine how much effort a patient puts forth and how high or low he/she sets goals. People with strong self-efficacy tend to persevere through obstacles and are more likely to learn and regularly use new behaviors to manage their health condition.6
Methods for Encouraging and Facilitating Self-efficacy
There is a vast body of literature indicating that people who have high self-efficacy for implementing new goals also have more successful outcomes.2 And obtaining successful outcomes is becoming more and more important as many hearing care services have fewer resources and an ever-increasing caseload because of the aging population.
In hearing rehabilitation, strong self-efficacy is needed for successful and consistent use of hearing aids and adjustment to amplified sound in a variety of environments. Self-efficacy also benefits tinnitus management and successful adjustment to cochlear or bone-anchored implants. Strong self-efficacy prompts the use of assertive, consistent conversational repair strategies, requests for clear speech with communication partners, and effective use of visual cues to enhance communication.
Self-efficacy has been shown to play a role in the decision-making process with hearing aids.7 It is required to master skills needed to use hearing aids and assistive technologies,8,9 and may be a predictor of successful hearing aid use.10
From a study that explored individuals’ beliefs in their ability to successfully use hearing aids in a variety of situations,11 researchers developed the Measure of Audiologic Rehabilitation Self-Efficacy for Hearing Aids (MARS-HA) that featured 24 items, including:
- A basic understanding of hearing aids (eg, inserting the battery, etc);
- Advanced handling (eg, trouble-shooting);
- Adjustment (eg, getting used to one’s own voice); and
- Aided listening (eg, speech understanding in group conversation).
When the MARS-HA was given to 211 new and experienced hearing aid users, lower self-efficacy was found in individuals with moderate-to-severe hearing loss and higher self-efficacy was found in individuals with mild loss.6 Researchers also noted lower self-efficacy in individuals with poor word recognition and higher self-efficacy in individuals with good-to-fair word recognition.11
Four approaches to increasing self-efficacy have been identified by Bandura5:
- Mastery experiences;
- Verbal persuasion;
- Vicarious experiences; andn Reduction of stress reactions.
Mastery experiences. Mastery experiences create a strong sense of self-efficacy and give truth to the adage, “Nothing breeds success like success.” If patients have been successful at a particular skill in the past, they will probably believe that they will be successful at the skill in the future. Conversely, failures undermine self-efficacy, particularly if the failure occurs before self-efficacy is firmly established for a behavior.
As hearing care professionals, we often spend a lot of time providing information about hearing loss or hearing aids, how they work, and how to troubleshoot; we don’t typically spend much time determining how confident the patient feels about executing our recommendations. This is where we should be focusing our interventions: knowing how confident the patient is to carry out the required new behavior is actually more important than knowing if the patient is motivated.
Rather than dismiss patients’ concerns and try to convince them it will be OK, identify exactly what their reservations are and then problem-solve together. For example, patients might feel that they are unable to insert the hearing aid correctly. Don’t try to convince the patient that it’s not a problem; let the patient gain confidence in self-efficacy through mastery of different skills. In this case, the way to structure the hearing aid orientation is to start with those aspects of manipulating and inserting the hearing aid that are the most simple so the patient can experience success. Gradually increase the patient’s ability to do more complex tasks.
Another patient might not feel confident about wearing a hearing aid for the first time. One could practice role playing in groups or with the spouse who comes to the appointment. For example, the role play could focus on wearing hearing aids in the office and how the patient might broach the topic, what to say, what reactions to expect, and how to cope with those reactions.
Self-advocacy. Ida Institute faculty member Sam Trychin, PhD, of Gallaudet University offered several practical approaches to helping adults develop self-efficacy in challenging everyday situations. He notes that it is not uncommon for patients to have low self-efficacy about their ability to inform others that they have a hearing loss. He stresses the importance of helping patients to understand the rationale and importance of this “essential communications behavior.”
One approach is to provide patients with examples of different ways to inform people and encourage patients to practice doing it in a way that feels comfortable. Offer feedback when patients have performed this task well. Feedback is important because a person may know it is important to inform others, but may do so in a way that turns people off (eg, by demanding, expressing anger, sounding pitiful, etc).
Practice in the hearing care office creates a safe environment for patients to deal with behaviors that have previously induced strong emotional reactions, including embarrassment, shame, or anxiety. Patients will also need to practice this behavior outside of the office. Dr Trychin points out that this essential behavior will be incorporated into a patient’s repertoire when he/she has succeeded in performing it in the outside world.
Verbal persuasion. Trouble-shooting is another approach that we commonly use when a patient comes into the office complaining of difficulties. If the patient says, “I’m having difficulty in noisy environments,” we begin to focus immediately on the problem area. More time spent identifying and unfolding what the patient is doing well and using verbal persuasion to provide positive reinforcement and encouragement might be a better way to foster confidence and a feeling of self-efficacy that would help the patient to more successfully address the problem areas.
Verbal persuasion helps to strengthen a patient’s belief that he/she has what it takes to succeed. Encourage the patient to focus on the more positive aspects of his/her behavior; those good feelings might then be transferred to still more challenging situations.
Vicarious experience. Group work is a very good way to increase self-efficacy through mastery experience and vicarious experience. But this is something that is seldom done by dispensing professionals. Group work provides a social context for practicing new communication skills. In addition, patients can begin to identify with the successes of the others in the group and can begin building confidence to do the same.
When a person sees another individual accomplish a task, the vicarious experience can have a positive impact on self-efficacy. By observing others like themselves perform tasks, patients make judgments about their own capabilities. Seeing people similar to oneself succeed raises an individual’s beliefs that he/she can master comparable activities required to succeed.
Observing this effective communication behavior provides the observer with information about what to say, how to say it, and that it is socially acceptable. Dr Trychin recommends encouraging patients to join and attend local or national events held by hearing loss advocacy groups, such as the Hearing Loss Association of American (HLAA), as one way to increase the probability that patients will be able to observe others modeling effective communication behaviors.
Seeing patients and their communication partners in a group setting is another highly efficient way of providing necessary information and training on effective communication behavior. In a group, the hearing care professional can directly observe participants’ communication behavior and offer corrective advice when necessary. It also provides an opportunity to assign homework to be carried out in various locations outside of the office, learn about the results of that experience, and provide corrective feedback about what to do differently next time.
Another easy way to encourage self-efficacy is to encourage patients to keep a hearing diary. Self-modeling, where patients observe themselves succeed, is a powerful influence. A hearing diary enables the patient to identify what is happening that is positive, describes clearly what challenges remain, and provides the possibility for establishing realistic goals. When they establish goals that are attainable, patients are able to build confidence and increase behavior changes. With a hearing diary, it is also possible to set tasks or jointly decide on specific activities before the next appointment.
Reducing stress. By reducing patients’ stress reactions, you can alter their negative emotional proclivities and their negative interpretations of their physical status.5 Help patients to identify when they are having a stress reaction. If they feel that they are becoming anxious when attempting to master a task, instruct them to stop doing the task until the stress comes down. Ask them to recognize the tactic or strategy they are doing in response to their stress and then evaluate if that is a positive or negative strategy to employ.
For example, when some people wear hearing aids for a long time during the day, they experience fatigue from the effort that they have to put into listening and being engaged in communication. Sometimes, at the end of the day, they want to switch off their hearing aids and relax. However, they may not always tell their communication partner or family members. They haven’t identified that they are feeling tired when they come home and simply want to switch off the hearing aid. This can lead to stress in the home. The spouse doesn’t know the patient is switching off the hearing aid and an argument ensues. If you can identify that the reason the patient switches off the hearing aids is because he/she is experiencing fatigue, then the spouse and patient might reach an agreement that, when a certain level of fatigue is reached, the person receives “time off.”
Self-efficacy Is Crucial
Is it possible to have a successful rehabilitation without strong self-efficacy? The answer is no. If patients do not have confidence in their ability to successfully follow the recommendations made by their hearing care provider, there is little chance that they will be able to succeed. Either they may not follow through with the recommendations or may go along with the recommendations but perceive that it is not a positive outcome. In effect, patients will passively go through the motions.
Sometimes a spouse may take ownership of the situation—putting in the hearing aid and making sure it is working. All the patient has to do is passively wear the hearing aids. In this situation, the patient is not actively involved in the rehabilitation process. The patient may be improving the spouse’s quality of life, but is not necessarily improving his/her personal quality of life.
Our goal is to help patients live well with hearing loss. Without a high sense of self-efficacy, people don’t change. They are simply drawn or go along with whatever recommendations you make. They don’t experience a sense that they are doing well. It is not a positive experience for them and as a consequence they are really not improving their lifestyle. Self-efficacy should be built as a first or critical goal of hearing rehabilitation in order to reach the goal of improved communication and improved quality of life.
- Hochbaum GM. Public participation in medical screening programs: A sociopsychological study. PHS publication no. 572. Washington, DC: US Government Printing Office; 1958.
- Glanz K, Marcus Lewis F, Rimer BK. Theory at a Glance: A Guide for Health Promotion Practice. National Institutes of Health; 1997. Available at: www.cancer.gov/cancertopics/cancerlibrary/theory.pdf. Accessed July 6, 2011.
- Rosenstock I. The health belief model: explaining health behavior through expectancies. In: Glanz K, Lewis F, Rimer B. eds. Health Behavior and Health Education. San Francisco: Jossey-Bass Publishers; 1990.
- Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall; 1986.
- Bandura A. Self-efficacy. In: VS Ramachaudran, ed. Encyclopedia of Human Behavior. Vol 4. New York: Academic Press; 1994:71-81. Available at: des.emory.edu/mfp/BanEncy.html. Accessed July 6, 2011.
- Smith SL, West RL. The application of self-efficacy principles to audiologic rehabilitation: a tutorial. Am J Audiol. 2006;15:46-56.
- Weinstein BE. Geriatric Audiology. New York: Thieme Medical; 2000.
- Kochkin S. MarkeTrak VII: Customer satisfaction with hearing instruments in the digital age. Hear Jour. 2005;58:30-43.
- Reese JL, Hnath-Chisolm T. Recognition of hearing aid orientation content by first-time users. Am J Audiol. 2005;14:94-104.
- Kricos PB. The influence of nonaudiological variables on audiological rehabilitation outcomes. Ear Hear. 2000;21:7Sâ€“14S.
- Smith SL, West RL, Kricos PB. Hearing aid self-efficacy of older adults. Poster session presented at: Annual meeting of the American Academy of Audiology; March 31-April 3, 2004; Salt Lake City.
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