Hearing Help-Seeking Behavior

Y-Garcia et al., 2012) and chronic pain (Slade et al., 2009). Finally, more perceived social support from friends and family is associated with greater likelihood of seeking and acquiring hearing aids (Laplante-Lévesque et al., 2013), as well as with better hypertension self-management (Flynn et al., 2013) and adherence to diabetic therapy (Miller & DiMatteo, 2013).

The implication of these parallels between help seeking for hearing loss and help seeking for other conditions is that we should look beyond audiology to the field of health psychology to understand hearing help-seeking behaviors and health behavior change, especially because there are many models that explain the underlying motivators, barriers, and facilitators of health behaviors that can be used to develop behavior change interventions. Indeed, such models have been used as the basis for developing smoking cessation programs (Ben Natan et al., 2010), understanding dietary choices (Sun et al., 2006), changing the use of hearing protection (Griest et al., 2007; Saunders et al., 2014), and creating diabetes management programs (Jennings et al., 2014). While no health behavior model can perfectly describe why and how health behavior changes occur, models are valuable because they provide insight into the interaction between various factors that influence health behaviors to facilitate or impede behavior change. Furthermore, models provide a basis from which to develop behavior change interventions, and data show that behavior change interventions with a theoretical basis tend to be more effective than interventions developed without a theoretical basis (National Cancer Institute, 2005; Noar & Zimmerman, 2005).

Recently, audiologic researchers have examined how health behavior theories can be applied to understand help seeking for hearing loss. This work is promising in that models are identifying barriers and facilitators to hearing help seeking. To illustrate this, some of the models and the associated work on hearing help seeking are described below.

Health Behavior Models for Help Seeking

Transtheoretical Model

The Transtheoretical Model (TTM) of behavior change was developed in the 1980s by Prochaska and colleagues (Prochaska & DiClemente, 1983; Prochaska & Velicer, 1997). The premise of the model is that an individual’s readiness for change determines whether he/she will engage in, and maintain, a health behavior. It is proposed that individuals move from being unready for change (precontemplation) to a stage at which change is being considered (contemplation), leading them to a time during which they prepare for change (preparation), until they reach the point at which behavior change occurs (action). That behavior may continue (maintenance), or it may stop (relapse). If the latter, the cycle begins again (Figure 8–1). The model acknowledges that progression is not necessarily continuous, in that individuals have the potential to progress and regress between stages. Movement between stages is affected by a process of decisional balance, which is the weighing of the perceived pros and cons of taking up the new behavior, and by the individual’s self-efficacy for conducting the new behavior, such that to progress from one stage to the next, the individual must perceive more pros than cons and believe in their capability to be successful. This model is not without its critics. Some have questioned whether stages of change should be described as categories or a continuum (Littell & Girvin, 2002), which in turn has raised questions as to whether the stages can be accurately measured (Bridle et al., 2005). Further, this model assumes a rational approach to decision making and largely ignores social and emotional influences. Nonetheless the constructs of the model can well describe hearing health behaviors (Table 8–1), and several studies have applied this model to hearing help seeking, as follows. (Editors’ note: For more information on the Transtheoretical Model, the reader is referred to Chapter 12 of this text.)

Figure 8–1. Transtheoretical Model.

Table 8–1. Transtheoretical Stages of Change Model: Definition of Constructs and Influences on Help Seeking for Hearing

In 2002, Milstein and Weinstein applied the TTM to understand the help seeking behaviors of individuals who failed a free hearing screening that took place at a senior center. Those who failed the screening were asked to identify with one of four statements representing the stages of change, ranging from “I do not think I have a hearing problem and therefore nothing should be done about it” (precontemplation) to “I know I have a hearing problem, and I am here to take action to solve it now” (action). If the TTM applies to hearing help seeking, one would expect the majority of individuals in this study to have agreed with the statement “I do not think I have a hearing problem and therefore nothing should be done about it.” This was indeed the case, with 76% of the 147 participants being in the precontemplation or contemplation stages of change. In the second part of the study, the 135 individuals who failed the hearing screening were given a written recommendation to have an audiological evaluation. Two weeks later, they were contacted by the investigators to find out whether they had had an audiologic evaluation, and the reason(s) for their decision. It turned out that there were no relationships between the stage of change at baseline and the individual’s help seeking behavior. However, given the short 2-week time frame, and the fact that almost all participants were in the precontemplation or contemplation stages of change, this is perhaps unsurprising. The reasons given by those who had had a hearing test said they did it to improve their quality of life, to find out their hearing status, because they were aware of hearing difficulties, and/or because it was recommended at the screening. The reasons for not getting a hearing test included having other health problems, having had no time to get a hearing test, and/or not noticing any hearing difficulties. Take note of these factors because they are relevant to some of the other health behavior models described below.

Laplante-Lévesque and colleagues used the TTM to examine hearing health behaviors in two studies. They examined the stage of change of 153 adults with acquired hearing loss who were seeking help for the first time (Laplante-Lévesque et al., 2013) and the stage of change of adults who failed an online hearing screening (Laplante-Lévesque et al., 2015) using a version of the University of Rhode Island Change Assessment (URICA; McConnaughy et al., 1983) adapted for hearing loss. Based on the TTM, one would predict that the first-time help seekers would be at a more advanced stage of change than those who failed an online hearing screening. Indeed, this was the case: almost 80% of the first-time help seekers were in the action stage of change, while in contrast, just 2.7% of the adults who had failed a hearing screening but had not sought help were in the action stage. The majority of the latter group was in the preparation stage (50%), with an additional 38% being in the contemplation stage. Laplante-Lévesque et al. (2013) also assessed whether the TTM had predictive validity. Using logistic regression analyses, they determined that 67% of the first-time help seekers who were in the action stage had taken up an intervention 6 months later, as compared with 33% of those who were in the preparation stage. Similar results were obtained by Saunders et al. (2016a), who found that 77.5% of their 182 first-time help seekers were in the action stage, with just 3.7% in the precontemplation stage and 16% in the contemplation stage. Furthermore, 6 months later, less than 15% of the individuals who were in the precontemplation stage at baseline had acquired hearing aids, while almost 80% of those in the action stage had acquired hearing aids (Saunders et al., 2016b).

Health Belief Model

The Health Belief Model (HBM) was developed in the 1950s by social psychologists in an attempt to understand why people were not taking up free health screenings to detect asymptomatic diseases. It was revised by Rosenstock (1966) to understand patients’ responses to illness symptoms and compliance with prescribed health care regimens and, later again, by Janz and Backer (1974). The current version of the model consists of six constructs that, together, aim to explain and predict health-related behaviors. The model postulates that the likelihood an individual will engage in a health behavior is determined by the extent to which he/she perceives a threat from a health condition. The perceived threat is affected by the interplay between the individual’s perception about the positive consequences of adopting the behavior (perceived benefits) and the negatives of doing so (perceived barriers), the individual’s assessment of the risk of having or acquiring the condition (perceived susceptibility), the seriousness of the consequences of the condition (perceived severity), the individual’s confidence in his/her ability to successfully adopt a behavior and of a successful outcome from the behavior (perceived self-efficacy), and by external influences (cues to action), such as symptoms, media communications, and information from a health care provider. Additionally, the HBM assumes that demographic and psychosocial variables such as age and personality influence the beliefs and attitudes associated with each construct. Figure 8–2 illustrates the way in which the constructs are thought to interact, and Table 8–2 describes how each construct can be applied in the context of hearing help seeking. As with the TTM, critics have pointed out that the model relies on rational decision making with little acknowledgment of the role of automatic motivational processes such as emotions and habits that affect behavior.

The HBM has been examined relatively extensively in the context of hearing help seeking. In 1996, van den Brink and colleagues developed an attitude questionnaire that assessed perceived severity, perceived benefits, perceived barriers, and cues to action (which van den Brink et al. refer to as “perceived social norm”). They determined that individuals who did not seek help for their hearing loss had significantly lower perceived severity and perceived benefits scores and had received fewer cues to action than those who had sought help. In a similar vein, Saunders et al. (2013) developed the Hearing Behaviors Questionnaire (HBQ) to assess all six constructs of the HBM. The HBQ was completed by 223 individuals, of whom 127 reported they had a hearing loss, 55 reported normal hearing, and 51 were unsure about their hearing status. Seventy-five had recently had their hearing tested and 44 owned hearing aids. Using logistic regression analysis, the HBQ correctly classified 78% of the non-help seekers as non-help seekers and 68% of the help seekers as help seekers, as well as 85% of the hearing aid owners as hearing aid owners and 77% of nonowners as nonowners.

Meyer at al. (2014) used a variety of measures to assess the constructs of the HBM among individuals who had or had not sought help for their hearing. They determined the help seekers saw more potential benefit from hearing aids, reported more activity limitations and had higher perceived ability to manage hearing aids than the non-help seekers—reflecting the HBM constructs of perceived benefits, perceived severity, and perceived self-efficacy, respectively. As with the participants of the Milstein and Weinstein (2002) study, the non-help seekers reported barriers (e.g., lack of time, cost), negative cues to action (e.g., others had negative experiences with hearing aids and/or significant others less supportive of hearing aids) and low perceived benefit (e.g., hearing not bad enough) as reasons for not seeking help.

Schulz et al. (2016, 2017) recently conducted a study to determine whether adding a seventh construct, “perceived burden on communication partners,” would enhance the predictive capability of the HBM for hearing help seeking. Using the HBQ of Saunders et al. (2013), and data from 413 older adults, they determined that the help seekers (n = 272) had significantly lower perceived benefits and cues to action scores, and significantly higher barriers scores, than non-help seekers. They also determine that adding the “perceived burden on communication partners” construct improved the fit of the model from correctly classifying 66.7% of individuals to correctly classifying 72% of individuals. (Editors’ note: For further discussion of the role of family and friends on hearing help seeking and on AR outcomes, the reader is referred to Chapter 16 of this text.)

It is also worth noting that other studies investigating help seeking indirectly illustrate the applicability of the HBM. For instance, when individuals were queried about why they had not sought help for symptoms of hearing loss, their responses reflected constructs of the HBM: “My hearing isn’t bad enough” (perceived severity), “Hearing aids won’t help me” (perceived benefits), “Hearing aids are too expensive” (perceived barrier), “I’ve got other things to worry about’” (perceived barriers), “Hearing aids are embarrassing/stigmatizing” (perceived barriers), “I don’t know where to go to get help” (self-efficacy), and “Others have had poor experiences with hearing aids” (cues to action). Likewise, reasons for seeking help included “hearing aids would improve quality of life/help maintain social participation” (perceived benefits), “I can’t cope without help” (perceived severity), “Hearing aids will decrease the burden on my friends/family” (cue to action), “Other people want me to get help for my hearing” (cue to action), or “Someday I will find a solution to my hearing loss” (self-efficacy) (e.g., Milstein & Weinstein 2002, Meyer et al., 2011; Rolfe & Gardner, 2016; Laplante-Lévesque et al., 2012; Fischer et al., 2011; Lockey et al., 2010; Southall et al., 2006, 2010; Schulz et al., 2017).